Provider Demographics
NPI:1003260126
Name:LUSSETTO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LUSSETTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-0430
Mailing Address - Country:US
Mailing Address - Phone:308-262-1574
Mailing Address - Fax:
Practice Address - Street 1:800 Q ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-2519
Practice Address - Country:US
Practice Address - Phone:308-262-1574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1717235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist