| NPI | 1609937978 |
|---|---|
| Former Name | MARY M LAKE |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CA PT 11967) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: CA PT 11967) |
| 2251X0800X Physical Therapist, Orthopedic (Licence: CA PT 11967) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2016-09-16 |