Provider Demographics
NPI:1225191521
Name:MCCREADY, LISA (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:MCCREADY
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BOSCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:6200 MENDIUS AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4124
Mailing Address - Country:US
Mailing Address - Phone:505-828-0481
Mailing Address - Fax:
Practice Address - Street 1:4210A LOUISIANA BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1807
Practice Address - Country:US
Practice Address - Phone:505-268-6593
Practice Address - Fax:505-268-0184
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist