Provider Demographics
NPI:1750062097
Name:LAKE, MELVINA SHARON (LMCSW)
Entity type:Individual
Prefix:MS
First Name:MELVINA
Middle Name:SHARON
Last Name:LAKE
Suffix:
Gender:F
Credentials:LMCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7083
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10150
Mailing Address - Country:US
Mailing Address - Phone:718-708-7911
Mailing Address - Fax:
Practice Address - Street 1:1881 SCHIEFFELIN PLACE #4F
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466
Practice Address - Country:US
Practice Address - Phone:718-708-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046956101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional