Active NPI
Candice M Lake, BCBA-D, LLP
- Behavior Analyst
- Grand Rapids, MI
National Provider Identifier
1285918193
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Behavior Analyst
- License
- 01-07-3561
- Practice address
- 1260 Ekhart St NE
Grand Rapids, MI 49503-1380 - Phone
- (616) 965-3470
- NPI assigned
- Oct 11, 2011
- Last updated
- Mar 21, 2016
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 6301016173 | MI | |
| Behavior Analyst | 103K00000X | 01-07-3561 | MI | Primary |
Addresses
Primary practice location
1260 Ekhart St NE
Grand Rapids, MI 49503-1380
Mailing address
3300 36TH St SE
Grand Rapids, MI 49512-2810
Phone (616) 965-3470
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 10025695700 | Medicaid | NE |
Other names 1
- Dr. Candice M Jostad
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6301016173 | MI | MD | Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wedgwood Christian Services | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Grand Rapids, MI
- NPI 1902997224
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1318291200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1458518400000",
"number": "1285918193",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3300 36TH ST SE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495122810",
"telephone_number": "616-965-3470"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1260 EKHART ST NE",
"city": "GRAND RAPIDS",
"state": "MI",
"postal_code": "495031380",
"telephone_number": "616-965-3470"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LAKE",
"first_name": "CANDICE",
"middle_name": "M",
"name_prefix": "Dr.",
"credential": "BCBA-D, LLP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2011-10-11",
"last_updated": "2016-03-21",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MI",
"license": "6301016173",
"primary": false
},
{
"code": "103K00000X",
"taxonomy_group": "",
"desc": "Behavior Analyst",
"state": "MI",
"license": "01-07-3561",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "10025695700",
"state": "NE"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "CANDICE",
"last_name": "JOSTAD",
"middle_name": "M",
"prefix": "DR.",
"credential": "BCBA-D, LLP",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Grand Rapids, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.