Provider Demographics
NPI:1659789162
Name:LAKE, ELIZABETH (PTA)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 OSPREY LN
Mailing Address - Street 2:P.O. BOX 209
Mailing Address - City:DOWELL
Mailing Address - State:MD
Mailing Address - Zip Code:20629-3016
Mailing Address - Country:US
Mailing Address - Phone:410-610-8251
Mailing Address - Fax:
Practice Address - Street 1:101 E STATE ST
Practice Address - Street 2:
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-3109
Practice Address - Country:US
Practice Address - Phone:410-326-8156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4146225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant