Provider Demographics
NPI:1568651107
Name:CASSIDY STULTZ, LISA MICHELLE (MS CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:CASSIDY STULTZ
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:18 ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1216
Mailing Address - Country:US
Mailing Address - Phone:317-374-6947
Mailing Address - Fax:
Practice Address - Street 1:2141 N DAN JONES RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6023
Practice Address - Country:US
Practice Address - Phone:317-943-1837
Practice Address - Fax:317-780-3750
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004181A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist