Provider Demographics
NPI:1912045402
Name:BYWATER, LISA W (MS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:W
Last Name:BYWATER
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 1:108 WHITMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1754
Mailing Address - Country:US
Mailing Address - Phone:860-521-2646
Mailing Address - Fax:
Practice Address - Street 1:139 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1264
Practice Address - Country:US
Practice Address - Phone:860-570-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03378709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist