Provider Demographics
NPI:1033702287
Name:LAKE, ELIZABETH NICOLE (MA, BCBA/LBA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:LAKE
Suffix:
Gender:
Credentials:MA, BCBA/LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:281-826-3382
Mailing Address - Fax:425-491-7683
Practice Address - Street 1:5457 SW CANYON CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2401
Practice Address - Country:US
Practice Address - Phone:971-762-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1-22-63133103K00000X
WA1-22-63133103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst