Provider Demographics
NPI:1396862264
Name:LAKE, JOSLIN (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:JOSLIN
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N VERDUGO RD APT 162
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2939
Mailing Address - Country:US
Mailing Address - Phone:919-522-6726
Mailing Address - Fax:
Practice Address - Street 1:250 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-2456
Practice Address - Country:US
Practice Address - Phone:805-494-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22122235Z00000X
NC5992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty