Provider Demographics
NPI:1831464437
Name:MCGONEGAL-SMITH, LISA LYN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYN
Last Name:MCGONEGAL-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 E BROOMFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-4449
Mailing Address - Country:US
Mailing Address - Phone:989-773-1209
Mailing Address - Fax:989-773-4267
Practice Address - Street 1:1290 E BROOMFIELD ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4449
Practice Address - Country:US
Practice Address - Phone:989-773-1209
Practice Address - Fax:989-773-4267
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI35010029832355A2700X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology Assistant