Provider Demographics
NPI:1306974241
Name:LAKE, DONNA ANN (OTR)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:ANN
Last Name:LAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MACLOVIA LN
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3247
Mailing Address - Country:US
Mailing Address - Phone:505-474-4218
Mailing Address - Fax:
Practice Address - Street 1:1300 CAMINO SIERRA VIS
Practice Address - Street 2:BF YOUNG CENTER
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1007
Practice Address - Country:US
Practice Address - Phone:505-954-2504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM276225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR7077Medicaid