Provider Demographics
NPI:1992998900
Name:LAKE, AMANDA KAY
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-3812
Mailing Address - Country:US
Mailing Address - Phone:608-743-2417
Mailing Address - Fax:608-743-2406
Practice Address - Street 1:113 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3812
Practice Address - Country:US
Practice Address - Phone:608-743-2417
Practice Address - Fax:608-743-2406
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA10097101YA0400X
WI15750101YA0400X
IA000347106H00000X
WI903106H00000X
IL166000869106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)