Provider Demographics
NPI:1346755634
Name:WILLOUGHBY, LISA ANN (MS,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WILLOUGHBY
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 1:327 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08008-4918
Mailing Address - Country:US
Mailing Address - Phone:609-234-1796
Mailing Address - Fax:
Practice Address - Street 1:1064 S MAIN ST BLDG 2C
Practice Address - Street 2:
Practice Address - City:WEST CREEK
Practice Address - State:NJ
Practice Address - Zip Code:08092-2914
Practice Address - Country:US
Practice Address - Phone:609-234-1796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00335300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist