Provider Demographics
NPI:1023158086
Name:MILLBOURN, MARY LISA (MA, CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LISA
Last Name:MILLBOURN
Suffix:
Gender:F
Credentials:MA, CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 COCOANUT AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34234-4658
Mailing Address - Country:US
Mailing Address - Phone:941-351-5550
Mailing Address - Fax:
Practice Address - Street 1:5661 RAND BOULEVARD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238
Practice Address - Country:US
Practice Address - Phone:941-927-8805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist