Provider Demographics
NPI:1568780385
Name:LAKE, BONNIE SUE (OT)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:SUE
Last Name:LAKE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NW 7TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1212
Mailing Address - Country:US
Mailing Address - Phone:405-609-3675
Mailing Address - Fax:800-506-3795
Practice Address - Street 1:1425 S SANTA FE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5901
Practice Address - Country:US
Practice Address - Phone:405-285-8845
Practice Address - Fax:405-285-8848
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1070225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200286380AMedicaid
OK200286380AMedicaid