Provider Demographics
NPI:1669621827
Name:LAKE, MALEIA SUZANNE-ROME (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MALEIA
Middle Name:SUZANNE-ROME
Last Name:LAKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:MALEIA
Other - Middle Name:SUZANNE
Other - Last Name:ROME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1407 N 195TH STREET
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6415
Mailing Address - Country:US
Mailing Address - Phone:402-332-7566
Mailing Address - Fax:
Practice Address - Street 1:10791 S 72ND ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-3423
Practice Address - Country:US
Practice Address - Phone:402-932-2782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT9464225X00000X
NE1364225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist