Healthcare Provider Details

I. General information

NPI: 1518820778
Provider Name (Legal Business Name): CARRIE LAKE HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PLEASANT VALLEY RD
WEST BEND WI
53095-9274
US

IV. Provider business mailing address

3200 PLEASANT VALLEY RD
WEST BEND WI
53095-9274
US

V. Phone/Fax

Practice location:
  • Phone: 262-836-7300
  • Fax:
Mailing address:
  • Phone: 262-836-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: