Provider Demographics
NPI:1669873931
Name:LAKE, ALYSON BUTLER (AU-D)
Entity type:Individual
Prefix:MRS
First Name:ALYSON
Middle Name:BUTLER
Last Name:LAKE
Suffix:
Gender:F
Credentials:AU-D
Other - Prefix:MISS
Other - First Name:ALYSON
Other - Middle Name:KATHLEEN
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15243 FOREST RD STE D
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4974
Mailing Address - Country:US
Mailing Address - Phone:434-266-9898
Mailing Address - Fax:434-266-9848
Practice Address - Street 1:15243 FOREST RD STE D
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4974
Practice Address - Country:US
Practice Address - Phone:434-266-9898
Practice Address - Fax:434-266-9848
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101002089237600000X
VA2201001518231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter