Provider Demographics
NPI:1386419232
Name:LAKE, TAMERA NICOLE (LSW)
Entity type:Individual
Prefix:
First Name:TAMERA
Middle Name:NICOLE
Last Name:LAKE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW
Mailing Address - Street 1:260 E GAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4653 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-3298
Practice Address - Country:US
Practice Address - Phone:614-875-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS.2411297OtherSOCIAL WORK