Provider Demographics
NPI:1942338181
Name:LACHES, MARY LISA (MS)
Entity Type:Individual
Prefix:MS
First Name:MARY LISA
Middle Name:
Last Name:LACHES
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 1:18012 FOREST RETREAT LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3165
Mailing Address - Country:US
Mailing Address - Phone:813-907-0284
Mailing Address - Fax:
Practice Address - Street 1:2125 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5918
Practice Address - Country:US
Practice Address - Phone:863-687-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4467235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist