Provider Demographics
NPI:1881777001
Name:LAKE, RICHARD WAYNE (LMFT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WAYNE
Last Name:LAKE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 LEROY RD
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:KY
Mailing Address - Zip Code:42413-9657
Mailing Address - Country:US
Mailing Address - Phone:270-875-2544
Mailing Address - Fax:270-342-5411
Practice Address - Street 1:345 LEROY RD
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:KY
Practice Address - Zip Code:42413-9657
Practice Address - Country:US
Practice Address - Phone:270-875-2544
Practice Address - Fax:270-342-5411
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0503106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100287010Medicaid