Provider Demographics
NPI:1104640283
Name:LAKE, KIRSTEN (LMSW)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 MCCORMICK RD SUITE 600,
Mailing Address - Street 2:EXECUTIVE SUITE III
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 MCCORMICK RD SUITE 600,
Practice Address - Street 2:EXECUTIVE SUITE III
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21031
Practice Address - Country:US
Practice Address - Phone:443-708-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD32490104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker