Provider Demographics
NPI:1326417346
Name:PEDI, LISA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PEDI
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 1:7 SAINT LUKES PL
Mailing Address - Street 2:APT. 102
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2119
Mailing Address - Country:US
Mailing Address - Phone:914-552-0039
Mailing Address - Fax:
Practice Address - Street 1:7 SAINT LUKES PL
Practice Address - Street 2:APT. 102
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2119
Practice Address - Country:US
Practice Address - Phone:914-552-0039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00757000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist