Provider Demographics
NPI:1265596035
Name:LAKE, MICHAEL H JR (LMHC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:H
Last Name:LAKE
Suffix:JR
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EAST SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3122
Mailing Address - Country:US
Mailing Address - Phone:321-722-5200
Mailing Address - Fax:321-953-7510
Practice Address - Street 1:4450 EAU GALLIE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7214
Practice Address - Country:US
Practice Address - Phone:321-726-2860
Practice Address - Fax:321-752-3143
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FLMH8204171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016517700Medicaid
FL000761700Medicaid