Provider Demographics
NPI:1336378751
Name:HENDERSON, LISA MARIE (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC/SLP
Mailing Address - Street 1:215 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-4211
Mailing Address - Country:US
Mailing Address - Phone:607-428-0641
Mailing Address - Fax:
Practice Address - Street 1:215 COVERED BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-4211
Practice Address - Country:US
Practice Address - Phone:607-437-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008665-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist