Provider Demographics
NPI:1285827493
Name:IVY, LISA FRATESI (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FRATESI
Last Name:IVY
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 GEORGE HALL, REBEL DRIVE
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY
Mailing Address - State:MS
Mailing Address - Zip Code:38677-8800
Mailing Address - Country:US
Mailing Address - Phone:662-915-5291
Mailing Address - Fax:662-915-7263
Practice Address - Street 1:206 GEORGE HALL, REBEL DRIVE
Practice Address - Street 2:
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677-8800
Practice Address - Country:US
Practice Address - Phone:662-915-5291
Practice Address - Fax:662-915-7263
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03275793Medicaid