Provider Demographics
NPI:1689620106
Name:LAKE, STEPHEN TAYLOR (MPT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TAYLOR
Last Name:LAKE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CRESCENT CENTRE DR STE 600
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7286
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:4957 SWINYAR DR STE 103
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-2205
Practice Address - Country:US
Practice Address - Phone:423-664-0800
Practice Address - Fax:423-664-0801
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3705225100000X
GAPT004097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446652Medicaid
TN3156797OtherBCBST - GROUP NUMBER
TN5441437Medicaid
TN0446652Medicaid