Provider Demographics
NPI:1922555705
Name:LAKE, MARION A (LCSW)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:A
Last Name:LAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 KELTONWOOD RD APT 2208
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-7030
Mailing Address - Country:US
Mailing Address - Phone:980-785-1500
Mailing Address - Fax:
Practice Address - Street 1:3506 W TYVOLA RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-7201
Practice Address - Country:US
Practice Address - Phone:704-329-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0147911041C0700X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)