Provider Demographics
NPI:1659502979
Name:LAKE, WARREN JAMES (PT)
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:JAMES
Last Name:LAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8993 W IRMA LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-6479
Mailing Address - Country:US
Mailing Address - Phone:801-916-0030
Mailing Address - Fax:
Practice Address - Street 1:1530 W GLENDALE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-8578
Practice Address - Country:US
Practice Address - Phone:602-242-1909
Practice Address - Fax:877-375-0934
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist