Provider Demographics
NPI:1063399095
Name:LAKE, JOSEPH MYCHAYLO (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MYCHAYLO
Last Name:LAKE
Suffix:
Gender:M
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 1:650 1ST AVE SE # 202
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-2744
Mailing Address - Country:US
Mailing Address - Phone:541-981-9983
Mailing Address - Fax:
Practice Address - Street 1:385 TIMBER RIDGE ST NE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-7425
Practice Address - Country:US
Practice Address - Phone:541-926-2118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17554235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist