Provider Demographics
NPI:1376805275
Name:LAKE, CARISSA LYNN (MS ED)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:LYNN
Last Name:LAKE
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:LYNN
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 LATHAM RD
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-1103
Mailing Address - Country:US
Mailing Address - Phone:518-269-2705
Mailing Address - Fax:
Practice Address - Street 1:2247 13TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3017
Practice Address - Country:US
Practice Address - Phone:518-273-1586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY484706101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist