Provider Demographics
NPI:1952329039
Name:COLLISON, LORI JAYNE (MS)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:JAYNE
Last Name:COLLISON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:JAYNE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 SAN MARCO DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3230
Mailing Address - Country:US
Mailing Address - Phone:941-485-4592
Mailing Address - Fax:941-485-0703
Practice Address - Street 1:105 SAN MARCO DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3230
Practice Address - Country:US
Practice Address - Phone:941-485-4592
Practice Address - Fax:941-485-0703
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY 452231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600484900Medicaid
FL600484900Medicaid
FLAB818YMedicare PIN