Healthcare Provider Details

I. General information

NPI: 1952910234
Provider Name (Legal Business Name): EMILY LAKE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S CREASY LN STE 100
LAFAYETTE IN
47905-7433
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-447-5552
  • Fax: 765-449-1054
Mailing address:
  • Phone: 765-446-5417
  • Fax: 765-446-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06006130A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: