Provider Demographics
NPI:1982856803
Name:CUNDALL, LISA R (MS)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:CUNDALL
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 1:414 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-1349
Mailing Address - Country:US
Mailing Address - Phone:618-344-4697
Mailing Address - Fax:
Practice Address - Street 1:414 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-1349
Practice Address - Country:US
Practice Address - Phone:618-344-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist