1376833376 NPI number — MRS. LISA SUSANNE BAILLARGEON CCC-SLP

Table of content: POLLY DIANNE RIVAS DDS (NPI 1740305028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376833376 NPI number — MRS. LISA SUSANNE BAILLARGEON CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILLARGEON
Provider First Name:
LISA
Provider Middle Name:
SUSANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376833376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 BUTTERNUT DR. STE. 8
Provider Second Line Business Mailing Address:
PMB #224
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 E. WOOLBRIGHT RD.
Provider Second Line Business Practice Location Address:
APT. B406
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-886-4568
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SA 10155 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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