Provider Demographics
NPI:1225194327
Name:PINELL, LISA D (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:PINELL
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 1:110 ELM ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2413
Mailing Address - Country:US
Mailing Address - Phone:985-209-1600
Mailing Address - Fax:
Practice Address - Street 1:741 BAYOU RD
Practice Address - Street 2:SUITE A
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2461
Practice Address - Country:US
Practice Address - Phone:985-209-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 3067235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1306215Medicaid