Basic Information
Provider Information | |||||||||
NPI: | 1215084116 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAKE | ||||||||
FirstName: | NAOMI | ||||||||
MiddleName: | BARRIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SOCIAL WORKER | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARRIE LAKE | ||||||||
OtherFirstName: | NAOMI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | SOCIAL WORKER | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 609001 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921609001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195284600 | ||||||||
FaxNumber: | 6195284625 | ||||||||
Practice Location | |||||||||
Address1: | 5353 MISSION CENTER RD STE 224 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921081304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196885855 | ||||||||
FaxNumber: | 6192913310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2007 | ||||||||
LastUpdateDate: | 07/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS17413 | CA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.