Provider Demographics
NPI:1306568886
Name:LAKE REGION FUNCTIONAL THERAPY LLC
Entity type:Organization
Organization Name:LAKE REGION FUNCTIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:ANGELICA
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:570-228-2248
Mailing Address - Street 1:2575 ROUTE 6 STE 2
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-7066
Mailing Address - Country:US
Mailing Address - Phone:570-228-2248
Mailing Address - Fax:570-227-1914
Practice Address - Street 1:2575 ROUTE 6 STE 2
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-7066
Practice Address - Country:US
Practice Address - Phone:570-228-2248
Practice Address - Fax:570-227-1914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty