Provider Demographics
NPI:1356217913
Name:LAKE, JAMES ANDREW (LCMFT, SCC-C, DMINN)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ANDREW
Last Name:LAKE
Suffix:
Gender:M
Credentials:LCMFT, SCC-C, DMINN
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:ANDY
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMFT, SCC-C, DMINN
Mailing Address - Street 1:4461 BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7221
Mailing Address - Country:US
Mailing Address - Phone:330-333-1909
Mailing Address - Fax:
Practice Address - Street 1:4461 BUCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7221
Practice Address - Country:US
Practice Address - Phone:330-333-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLCMFT0559020423101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty