Provider Demographics
NPI:1023376902
Name:HENRY, LISA MARIE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:HENRY
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 1:6371 PINCHERRY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:NY
Mailing Address - Zip Code:14085-9595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 DICKINSON ST
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:NY
Practice Address - Zip Code:14136-1637
Practice Address - Country:US
Practice Address - Phone:716-934-9603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008517-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist