Provider Demographics
NPI:1700179926
Name:DELONG, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DELONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1491 WHITEMAN GULLY RD
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-9405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1491 WHITEMAN GULLY RD
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9405
Practice Address - Country:US
Practice Address - Phone:585-519-7826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist