Provider Demographics
NPI:1053705418
Name:LAKE, SUZANNE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 MATTHEWS TOWNSHIP PKWY
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-2387
Mailing Address - Country:US
Mailing Address - Phone:704-384-6631
Mailing Address - Fax:704-384-6636
Practice Address - Street 1:1450 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-2387
Practice Address - Country:US
Practice Address - Phone:704-384-6631
Practice Address - Fax:704-384-6636
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7124235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist