Provider Demographics
NPI:1790019982
Name:LAKE, ANNE
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9221 E BASELINE RD
Mailing Address - Street 2:STE 109 #193
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209
Mailing Address - Country:US
Mailing Address - Phone:480-808-0665
Mailing Address - Fax:
Practice Address - Street 1:9818 E NAVARRO AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2518
Practice Address - Country:US
Practice Address - Phone:480-808-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist