Provider Demographics
NPI:1023624483
Name:LAKE, KATHERINE HAILEY (OTR/L)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HAILEY
Last Name:LAKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 COUNTY ROAD C W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1352
Mailing Address - Country:US
Mailing Address - Phone:651-638-0080
Mailing Address - Fax:651-638-0082
Practice Address - Street 1:1835 COUNTY ROAD C W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1352
Practice Address - Country:US
Practice Address - Phone:651-638-0080
Practice Address - Fax:651-638-0020
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107723225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist