Healthcare Provider Details

I. General information

NPI: 1720910748
Provider Name (Legal Business Name): HOLLY LAVAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39245 CALLE DE FORTUNA
MURRIETA CA
92563-8002
US

IV. Provider business mailing address

39245 CALLE DE FORTUNA
MURRIETA CA
92563-8002
US

V. Phone/Fax

Practice location:
  • Phone: 951-696-3503
  • Fax:
Mailing address:
  • Phone: 951-696-3503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number32086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: