Provider Demographics
NPI:1629162680
Name:HARRISON, LISA A (MSCCC;SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MSCCC;SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 JUDSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580
Mailing Address - Country:US
Mailing Address - Phone:585-350-9888
Mailing Address - Fax:
Practice Address - Street 1:965 N GOODMAN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-3930
Practice Address - Country:US
Practice Address - Phone:585-350-9888
Practice Address - Fax:585-288-3654
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015252-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30-0213081OtherTAX ID