Provider Demographics
NPI:1619173812
Name:LASALLE, LISA RENEE (CCC-SLP, BRFS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:LASALLE
Suffix:
Gender:F
Credentials:CCC-SLP, BRFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3725
Mailing Address - Country:US
Mailing Address - Phone:715-831-8254
Mailing Address - Fax:
Practice Address - Street 1:516 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3725
Practice Address - Country:US
Practice Address - Phone:715-831-8254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1936 - 154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist