Provider Demographics
NPI:1073200168
Name:CAFOLLA, LISA MARIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CAFOLLA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 NICKLAUS LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-3860
Mailing Address - Country:US
Mailing Address - Phone:732-966-4824
Mailing Address - Fax:
Practice Address - Street 1:766 BROAD ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4203
Practice Address - Country:US
Practice Address - Phone:855-428-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01198600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ41YS01198600OtherNJ LICENSE