Provider Demographics
NPI:1881615631
Name:LAKE, BEVERLY JEAN (MSW)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:JEAN
Last Name:LAKE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5493 GREENWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-7207
Mailing Address - Country:US
Mailing Address - Phone:734-692-0382
Mailing Address - Fax:
Practice Address - Street 1:20600 EUREKA ROAD
Practice Address - Street 2:SUITE 819
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:734-285-8282
Practice Address - Fax:734-281-0402
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801011987104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q26429044Medicare ID - Type Unspecified