Provider Demographics
NPI:1043523806
Name:WILLMUTH, LISA (CCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILLMUTH
Suffix:
Gender:F
Credentials:CCC
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 1753
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29465-1753
Mailing Address - Country:US
Mailing Address - Phone:843-216-0290
Mailing Address - Fax:843-216-2445
Practice Address - Street 1:1127 QUEENSBOROUGH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5431
Practice Address - Country:US
Practice Address - Phone:843-216-0290
Practice Address - Fax:843-216-2445
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist