Individual
MS. KIMMY JO LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CDP
Contact information
Practice address
758 ST HELENS AVE, TACOMA, WA 98402-3706
(253) 274-0484
(253) 274-1457
Mailing address
758 ST HELENS AVE, TACOMA, WA 98402-3706
(253) 274-0484
(253) 274-1457
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
CP60311481
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1003939034
—
WA
Enumeration date
05/14/2013
Last updated
05/14/2013
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