Provider Demographics
NPI:1760502082
Name:CASEY, LISA MULBRANDON (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MULBRANDON
Last Name:CASEY
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 1:323 OTIS AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3114
Mailing Address - Country:US
Mailing Address - Phone:630-435-4834
Mailing Address - Fax:
Practice Address - Street 1:323 OTIS AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3114
Practice Address - Country:US
Practice Address - Phone:630-435-4834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA2741KD1Medicaid