Provider Demographics
NPI:1336818301
Name:LAKE, ETHAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LAKE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:
Practice Address - Street 1:80 HIGHWAY 304
Practice Address - Street 2:
Practice Address - City:CALERA
Practice Address - State:AL
Practice Address - Zip Code:35040-5551
Practice Address - Country:US
Practice Address - Phone:205-668-6900
Practice Address - Fax:205-668-2677
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH10621225100000X
AL1-1177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist