Provider Demographics
NPI:1740760065
Name:KECK, LISA ANN (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:KECK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:3700 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0541
Practice Address - Country:US
Practice Address - Phone:812-485-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005117A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist