Individual
DR. CANDICE M LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BCBA-D, LLP
Contact information
Practice address
1260 EKHART ST NE, GRAND RAPIDS, MI 49503-1380
(616) 965-3470
Mailing address
3300 36TH ST SE, GRAND RAPIDS, MI 49512-2810
(616) 965-3470
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
01-07-3561
MI
103T00000X
Psychologist
6301016173
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10025695700
—
NE
Enumeration date
10/11/2011
Last updated
03/21/2016
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