Provider Demographics
NPI:1376833376
Name:BAILLARGEON, LISA SUSANNE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SUSANNE
Last Name:BAILLARGEON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 BUTTERNUT DR. STE. 8
Mailing Address - Street 2:PMB #224
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 E. WOOLBRIGHT RD.
Practice Address - Street 2:APT. B406
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435
Practice Address - Country:US
Practice Address - Phone:616-886-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 10155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist