Provider Demographics
NPI:1699829168
Name:LAKE, RICHARD D (MS, LMHC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:D
Last Name:LAKE
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10115 63RD AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1165
Mailing Address - Country:US
Mailing Address - Phone:253-904-8592
Mailing Address - Fax:253-904-8592
Practice Address - Street 1:10116 116TH ST E
Practice Address - Street 2:SUITE 202
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3543
Practice Address - Country:US
Practice Address - Phone:253-904-8592
Practice Address - Fax:253-904-8592
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health