Provider Demographics
NPI:1942270194
Name:LAKE, NANCY BIRGITTA (LISW, BCD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:BIRGITTA
Last Name:LAKE
Suffix:
Gender:F
Credentials:LISW, BCD
Other - Prefix:
Other - First Name:N.
Other - Middle Name:BIRGITTA
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:332 S LINN ST
Mailing Address - Street 2:SUITE 17
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-1608
Mailing Address - Country:US
Mailing Address - Phone:319-338-5181
Mailing Address - Fax:
Practice Address - Street 1:332 S LINN ST
Practice Address - Street 2:SUITE 17
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-1608
Practice Address - Country:US
Practice Address - Phone:319-338-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA014391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI4703Medicare ID - Type Unspecified