Provider Demographics
NPI:1306205554
Name:LAKE, KATRINA MARIE-VANDENBERG (PT)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:MARIE-VANDENBERG
Last Name:LAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 SEABRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2528
Mailing Address - Country:US
Mailing Address - Phone:831-458-6230
Mailing Address - Fax:
Practice Address - Street 1:1529 SEABRIGHT AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2528
Practice Address - Country:US
Practice Address - Phone:831-458-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist