Provider Demographics
NPI:1851425524
Name:LAKE, SAMANA B (PT)
Entity Type:Individual
Prefix:MS
First Name:SAMANA
Middle Name:B
Last Name:LAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:SHERI
Other - Middle Name:B
Other - Last Name:JASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:345 BIRCH HILLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622
Mailing Address - Country:US
Mailing Address - Phone:312-256-5662
Mailing Address - Fax:
Practice Address - Street 1:279 RIDGE RD. WEST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615
Practice Address - Country:US
Practice Address - Phone:585-254-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070005977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070005977OtherLICENSE IN IL
IL070005977OtherLICENSE IN IL
IL207137Medicare ID - Type UnspecifiedMEDICARE GROUP ID