Provider Demographics
NPI:1750586582
Name:LAKE, SUSAN P (MED)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:LAKE
Suffix:
Gender:F
Credentials:MED
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 12
Mailing Address - Street 2:
Mailing Address - City:ALLENSPARK
Mailing Address - State:CO
Mailing Address - Zip Code:80510-0012
Mailing Address - Country:US
Mailing Address - Phone:303-747-0293
Mailing Address - Fax:
Practice Address - Street 1:518 MEADOW MOUNTAIN DR.
Practice Address - Street 2:518 MEADOW MOUNTAIN DR.
Practice Address - City:ALLENSPARK
Practice Address - State:CO
Practice Address - Zip Code:80510-0012
Practice Address - Country:US
Practice Address - Phone:303-747-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist