Provider Demographics
NPI:1700115441
Name:EGGLESTON, LISA (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EGGLESTON
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 1:107 CORNWALL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2493
Mailing Address - Country:US
Mailing Address - Phone:304-744-4285
Mailing Address - Fax:
Practice Address - Street 1:107 CORNWALL LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2493
Practice Address - Country:US
Practice Address - Phone:304-744-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09144407235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist