Provider Demographics
NPI:1891394508
Name:GAEDE, LISA KAY (MS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KAY
Last Name:GAEDE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-9001
Mailing Address - Country:US
Mailing Address - Phone:715-896-8373
Mailing Address - Fax:
Practice Address - Street 1:424 RIVER DR
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-9001
Practice Address - Country:US
Practice Address - Phone:715-896-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1590035482235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty