Provider Demographics
NPI:1710434295
Name:LAKE, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 SUNCREST LOOP
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707
Mailing Address - Country:US
Mailing Address - Phone:407-927-6522
Mailing Address - Fax:
Practice Address - Street 1:125 S SWOOPE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5784
Practice Address - Country:US
Practice Address - Phone:407-968-8349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst