Provider Demographics
NPI:1083252431
Name:BLANCHETTE, LISA (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLANCHETTE
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 VALENTINE RD
Mailing Address - Street 2:
Mailing Address - City:POMFRET CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06259-2116
Mailing Address - Country:US
Mailing Address - Phone:203-331-5412
Mailing Address - Fax:
Practice Address - Street 1:261 VALENTINE RD
Practice Address - Street 2:
Practice Address - City:POMFRET CENTER
Practice Address - State:CT
Practice Address - Zip Code:06259-2116
Practice Address - Country:US
Practice Address - Phone:203-331-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004529235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist