Healthcare Provider Details

I. General information

NPI: 1083527121
Provider Name (Legal Business Name): CARYN MELISSA LAKE M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E MOUNT DIABLO AVE
TRACY CA
95376-4621
US

IV. Provider business mailing address

1020 W 4TH ST
RIPON CA
95366-2315
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number29867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: