Provider Demographics
NPI:1821203100
Name:LAKE, MARY T (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:LAKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15700 TERRACE DR # P102
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2959
Mailing Address - Country:US
Mailing Address - Phone:708-717-4924
Mailing Address - Fax:815-464-8431
Practice Address - Street 1:15700 TERRACE DR # P102
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2959
Practice Address - Country:US
Practice Address - Phone:708-717-4924
Practice Address - Fax:815-464-8431
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist