Provider Demographics
NPI:1972866721
Name:LAKE, ALLEN II (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:
Last Name:LAKE
Suffix:II
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E D ST STE J
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3252
Mailing Address - Country:US
Mailing Address - Phone:707-413-7680
Mailing Address - Fax:
Practice Address - Street 1:110 E D ST STE J
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-3252
Practice Address - Country:US
Practice Address - Phone:707-413-7680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93488101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA484821OtherDRUG MEDI-CAL
CA84-4657784OtherMENTAL HEALTH THERAPY