Provider Demographics
NPI:1669643151
Name:MACKALL, LISABETH HOUSTON (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISABETH
Middle Name:HOUSTON
Last Name:MACKALL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LOVELL AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4419
Mailing Address - Country:US
Mailing Address - Phone:612-437-0213
Mailing Address - Fax:
Practice Address - Street 1:1000 LOVELL AVE W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4419
Practice Address - Country:US
Practice Address - Phone:612-437-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7658235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist