Provider Demographics
NPI:1245577535
Name:GARDNER, LISA MARIE (MS, CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 S CLARK ST APT 305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1546
Mailing Address - Country:US
Mailing Address - Phone:781-424-4123
Mailing Address - Fax:
Practice Address - Street 1:547 S CLARK ST APT 305
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-1546
Practice Address - Country:US
Practice Address - Phone:781-424-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist