Provider Demographics
NPI:1023416146
Name:COUNSELING ASSOCIATES AT THE LAKE, INC.
Entity type:Organization
Organization Name:COUNSELING ASSOCIATES AT THE LAKE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LITTLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-301-5424
Mailing Address - Street 1:19501 W CATAWBA AVE
Mailing Address - Street 2:MAILBOX 10
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4017
Mailing Address - Country:US
Mailing Address - Phone:704-301-5424
Mailing Address - Fax:
Practice Address - Street 1:19501 W CATAWBA AVE
Practice Address - Street 2:MAILBOX 10
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4017
Practice Address - Country:US
Practice Address - Phone:704-301-5424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO29121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty