Provider Demographics
NPI:1891893699
Name:LAKE, RICKY B JR (LPC)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:B
Last Name:LAKE
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 OLD PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16002-3809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:793 OLD ROUTE 119 HWY N
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-1372
Practice Address - Country:US
Practice Address - Phone:724-465-5576
Practice Address - Fax:724-465-5532
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional