Provider Demographics
NPI:1205966397
Name:RAE, LISA HULL (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:HULL
Last Name:RAE
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 1:22672 LAMBERT ST
Mailing Address - Street 2:SUITE 607
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1613
Mailing Address - Country:US
Mailing Address - Phone:949-458-1113
Mailing Address - Fax:949-707-0044
Practice Address - Street 1:22672 LAMBERT ST
Practice Address - Street 2:SUITE 607
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1613
Practice Address - Country:US
Practice Address - Phone:949-458-1113
Practice Address - Fax:949-707-0044
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP12333235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist