| NPI | 1376950162 |
|---|---|
| Former Name | MARY ELISE LAKE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: CA PSY29809) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2014-07-14 |
| Last Update Date | 2019-05-13 |