Provider Demographics
NPI:1265766240
Name:PENK, LISA MICHELLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:PENK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:4714 W STONEHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9087
Mailing Address - Country:US
Mailing Address - Phone:317-910-0327
Mailing Address - Fax:
Practice Address - Street 1:8549 MADISON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6153
Practice Address - Country:US
Practice Address - Phone:317-881-9164
Practice Address - Fax:317-887-4060
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004846A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist