Provider Demographics
NPI:1972867067
Name:LAKE, KANDI MARIE
Entity Type:Individual
Prefix:
First Name:KANDI
Middle Name:MARIE
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 S 500 E
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-4057
Mailing Address - Country:US
Mailing Address - Phone:801-226-7696
Mailing Address - Fax:801-225-7053
Practice Address - Street 1:370 S 500 E
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-4057
Practice Address - Country:US
Practice Address - Phone:801-226-7696
Practice Address - Fax:801-225-7053
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor