Provider Demographics
NPI:1942408786
Name:MASTERSON, LILA LEE (ST)
Entity Type:Individual
Prefix:MRS
First Name:LILA
Middle Name:LEE
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:KY
Mailing Address - Zip Code:40037-7036
Mailing Address - Country:US
Mailing Address - Phone:270-865-3896
Mailing Address - Fax:
Practice Address - Street 1:1980 OLD GREENSBURG RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2536
Practice Address - Country:US
Practice Address - Phone:270-465-3506
Practice Address - Fax:270-789-4010
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1480235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1457424160Medicaid