Provider Demographics
NPI:1134667058
Name:LAKE, MISTY (LMT)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5125
Mailing Address - Country:US
Mailing Address - Phone:208-425-6891
Mailing Address - Fax:
Practice Address - Street 1:105 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5125
Practice Address - Country:US
Practice Address - Phone:208-425-6891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-11
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2923225700000X
WAMA00019204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist