Provider Demographics
NPI:1043894397
Name:MIODOWSKI, LISA MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MIODOWSKI
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40238 VINCENZIA DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-4084
Mailing Address - Country:US
Mailing Address - Phone:586-873-9967
Mailing Address - Fax:
Practice Address - Street 1:3400 LIVERNOIS RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5231
Practice Address - Country:US
Practice Address - Phone:248-282-6137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005140235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist