Provider Demographics
NPI:1639319015
Name:WAYNE UPTON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WAYNE UPTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1931 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3506
Mailing Address - Country:US
Mailing Address - Phone:203-384-8681
Mailing Address - Fax:
Practice Address - Street 1:728 POST RD E
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-5200
Practice Address - Country:US
Practice Address - Phone:203-341-0488
Practice Address - Fax:203-227-8809
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003813235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist