Provider Demographics
NPI:1700021680
Name:FARTHING, LISA (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FARTHING
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 RIO VILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3714
Mailing Address - Country:US
Mailing Address - Phone:321-773-7218
Mailing Address - Fax:
Practice Address - Street 1:412 RIO VILLA BLVD
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3714
Practice Address - Country:US
Practice Address - Phone:321-773-7218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8799235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist