Provider Demographics
NPI:1396984274
Name:LAKE-SANDERS, CRISTAL LYNN (NCC, LPC, MED)
Entity type:Individual
Prefix:MRS
First Name:CRISTAL
Middle Name:LYNN
Last Name:LAKE-SANDERS
Suffix:
Gender:F
Credentials:NCC, LPC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14308 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4302
Mailing Address - Country:US
Mailing Address - Phone:804-399-0676
Mailing Address - Fax:804-744-5202
Practice Address - Street 1:4906 MILLRIDGE PKWY E
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4828
Practice Address - Country:US
Practice Address - Phone:804-399-0676
Practice Address - Fax:804-744-5202
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004299101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992959928Medicaid