Provider Demographics
NPI:1851485429
Name:PEDERSON, LISA (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PEDERSON
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 1:1870 W WINCHESTER RD
Mailing Address - Street 2:203
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5358
Mailing Address - Country:US
Mailing Address - Phone:847-816-7200
Mailing Address - Fax:847-816-7210
Practice Address - Street 1:1870 W WINCHESTER RD
Practice Address - Street 2:203
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5358
Practice Address - Country:US
Practice Address - Phone:847-816-7200
Practice Address - Fax:847-816-7210
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist