Provider Demographics
NPI:1639328842
Name:COUGHLIN, LISA A (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:PODGORNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TSHH
Mailing Address - Street 1:137 CUSHING PL
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-2555
Mailing Address - Country:US
Mailing Address - Phone:716-821-9649
Mailing Address - Fax:
Practice Address - Street 1:137 CUSHING PL
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2555
Practice Address - Country:US
Practice Address - Phone:716-821-9649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016425-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist