Provider Demographics
NPI:1609105105
Name:BAXTER, LISA M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BAXTER
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 1:14299 BENEDICTINE LN
Mailing Address - Street 2:
Mailing Address - City:RIDGELY
Mailing Address - State:MD
Mailing Address - Zip Code:21660-1434
Mailing Address - Country:US
Mailing Address - Phone:106-342-1124
Mailing Address - Fax:
Practice Address - Street 1:14299 BENEDICTINE LN
Practice Address - Street 2:
Practice Address - City:RIDGELY
Practice Address - State:MD
Practice Address - Zip Code:21660-1434
Practice Address - Country:US
Practice Address - Phone:410-941-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06275235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist