Basic Information
| Provider Information | |||||||||
| NPI: | 1689620106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CRESCENT CENTRE DR STE 600 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370677286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153731350 | ||||||||
| FaxNumber: | 6152219054 | ||||||||
| Practice Location | |||||||||
| Address1: | 4957 SWINYAR DR STE 103 | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373632205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236640800 | ||||||||
| FaxNumber: | 4236640801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3705 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT004097 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0446652 | 05 | TN | MEDICAID | 3156797 | 01 | TN | BCBST - GROUP NUMBER | OTHER | 5441437 | 05 | TN | MEDICAID |