Provider Demographics
NPI:1295862498
Name:WEISEDEL, LISA A (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WEISEDEL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2168 WOODE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH COLLINS
Mailing Address - State:NY
Mailing Address - Zip Code:14111-9408
Mailing Address - Country:US
Mailing Address - Phone:716-337-0390
Mailing Address - Fax:
Practice Address - Street 1:10714 NORTH RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:NY
Practice Address - Zip Code:14129-9746
Practice Address - Country:US
Practice Address - Phone:716-532-1049
Practice Address - Fax:716-532-0679
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist