Provider Demographics
NPI:1043222391
Name:PRESCOTT, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:PRESCOTT
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 1:2410 RIKE DR
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-3935
Mailing Address - Country:US
Mailing Address - Phone:870-534-2035
Mailing Address - Fax:870-534-2058
Practice Address - Street 1:2410 RIKE DR
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-3935
Practice Address - Country:US
Practice Address - Phone:870-534-2035
Practice Address - Fax:870-534-2058
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP804235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122290721Medicaid