Provider Demographics
NPI:1669558540
Name:LAKIN, MICHAEL JON (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JON
Last Name:LAKIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N. CAYUGA ST.
Mailing Address - Street 2:BOX 30
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4329
Mailing Address - Country:US
Mailing Address - Phone:607-275-3727
Mailing Address - Fax:607-275-3727
Practice Address - Street 1:215 N CAYUGA ST
Practice Address - Street 2:SUITE 223
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4329
Practice Address - Country:US
Practice Address - Phone:607-275-3727
Practice Address - Fax:607-275-3727
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012562103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS43478Medicare UPIN
NYCC6030Medicare ID - Type UnspecifiedMEDICARE #