Provider Demographics
NPI:1720533581
Name:LAKE, MICHELLE (LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:A
Other - Last Name:CAMPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-5971
Practice Address - Fax:517-789-5918
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017419101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional