Provider Demographics
NPI:1679534242
Name:LAKE, ADAM W (MED, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:W
Last Name:LAKE
Suffix:
Gender:M
Credentials:MED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 BEELER DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1438
Mailing Address - Country:US
Mailing Address - Phone:440-554-8641
Mailing Address - Fax:
Practice Address - Street 1:29800 BAINBRIDGE RD
Practice Address - Street 2:CLEVELAND CLINIC SPORTS HEALTH
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2202
Practice Address - Country:US
Practice Address - Phone:440-914-8603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-0022302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer