Provider Demographics
NPI:1942271028
Name:LAKE, RICKIE INEZ BERRETT (LCSW)
Entity Type:Individual
Prefix:MS
First Name:RICKIE
Middle Name:INEZ BERRETT
Last Name:LAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:RICKIE
Other - Middle Name:BERRETT
Other - Last Name:LUNDSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5576 ALPINE POINT CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-9275
Mailing Address - Country:US
Mailing Address - Phone:801-835-3511
Mailing Address - Fax:
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1720
Practice Address - Country:US
Practice Address - Phone:801-263-7225
Practice Address - Fax:801-263-7279
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139965-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT262030OtherDESERT MUTUAL
UT942938348OtherCHAMPUS
UT942938348LA1OtherEDUCATORS MUTUAL
UT107001381101OtherINTERMOUNTAIN HEALTH CARE
UT942938348LA1OtherEDUCATORS MUTUAL