1548362056 NPI number — MRS. LISA RAE BLANTON MS/CCC-SLP

Table of content: MRS. LISA RAE BLANTON MS/CCC-SLP (NPI 1548362056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548362056 NPI number — MRS. LISA RAE BLANTON MS/CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANTON
Provider First Name:
LISA
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS/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:
1548362056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W2579 HALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEOSHO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53059-9522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-625-3147
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N3995 ANNEX RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53549-9618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-674-7386
Provider Business Practice Location Address Fax Number:
920-674-6694
Provider Enumeration Date:
09/04/2006

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:  1265-154 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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