Provider Demographics
NPI:1720533581
Name:LAKE, MICHELLE (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:A
Other - Last Name:CAMPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:226 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3652
Mailing Address - Country:US
Mailing Address - Phone:517-612-3037
Mailing Address - Fax:
Practice Address - Street 1:226 ORANGE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3652
Practice Address - Country:US
Practice Address - Phone:517-750-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI6401017419101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other