Provider Demographics
NPI:1588249726
Name:LAKE, MARVIDA FRANCES LOUISE
Entity type:Individual
Prefix:
First Name:MARVIDA
Middle Name:FRANCES LOUISE
Last Name:LAKE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3698
Mailing Address - Country:US
Mailing Address - Phone:919-741-3481
Mailing Address - Fax:
Practice Address - Street 1:8609 PARK AVENUE
Practice Address - Street 2:BOWIE
Practice Address - City:MARYLAND
Practice Address - State:MD
Practice Address - Zip Code:20720
Practice Address - Country:US
Practice Address - Phone:919-741-3481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11474101YM0800X
MDLC16469101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health