Provider Demographics
NPI:1508344383
Name:LAKE, CRYSTAL ANN (LMT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
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 1:5814 GRAHAM AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-2728
Mailing Address - Country:US
Mailing Address - Phone:253-891-7093
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:5814 GRAHAM AVE STE 101
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-2728
Practice Address - Country:US
Practice Address - Phone:253-891-7093
Practice Address - Fax:951-973-7216
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60879902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60879902OtherMASSAGE THERAPY LICENSE