Provider Demographics
NPI:1306545686
Name:LAKE, EILEEN (MFT LICENSE # 41076)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MFT LICENSE # 41076
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4577 WINNETKA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-4613
Mailing Address - Country:US
Mailing Address - Phone:818-307-0554
Mailing Address - Fax:
Practice Address - Street 1:4577 WINNETKA AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-4613
Practice Address - Country:US
Practice Address - Phone:818-307-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41076106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist