| Doctor Name: | MRS. EDNA LAKE |
| NPI Number: | 1558765305 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 1617675 |
| Business Practice Address: | 20 Lester Ln Middle Grove, NY - 128502410 |
| Business Phone Number: | 5182260777 |
| Business Fax Number: | |
| Mailing Address: | 20 Lester Ln, MIDDLE GROVE |
| State: | NY |
| Postal Code: | 128502410 |
| Phone Number: | 5182260777 |
| Fax Number: | |
| NPI Enumeration Date: | 10/21/2014 |
| NPI Last Update Date: | 10/21/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TS0200X |
| License Number: | 1617675 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |