Provider Demographics
NPI:1376677559
Name:TAKAOKA, LISA (MS CCC SLP L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TAKAOKA
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 1:615 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1085
Mailing Address - Country:US
Mailing Address - Phone:847-573-9265
Mailing Address - Fax:
Practice Address - Street 1:615 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1085
Practice Address - Country:US
Practice Address - Phone:847-573-9265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146004909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist