Provider Demographics
NPI:1922180165
Name:STROUD, CASSIE LAKE (MA, CCC-S)
Entity Type:Individual
Prefix:MS
First Name:CASSIE
Middle Name:LAKE
Last Name:STROUD
Suffix:
Gender:F
Credentials:MA, CCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510-0232
Mailing Address - Country:US
Mailing Address - Phone:304-736-8255
Mailing Address - Fax:304-736-4851
Practice Address - Street 1:3427 US ROUTE 60 EAST
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-736-8255
Practice Address - Fax:304-736-4851
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP0777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002490Medicaid