Basic Information
| Provider Information | |||||||||
| NPI: | 1235207002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14062 YELM HWY SE | ||||||||
| Address2: | |||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985979792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533806837 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539823685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00008946 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.