Provider Demographics
NPI:1275256588
Name:LAKE, MELISSA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W AVENUE M
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-8414
Mailing Address - Country:US
Mailing Address - Phone:325-657-4055
Mailing Address - Fax:325-657-4065
Practice Address - Street 1:323 PENROSE ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-8639
Practice Address - Country:US
Practice Address - Phone:325-659-3657
Practice Address - Fax:325-657-4086
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX756002404Medicaid