Provider Demographics
NPI:1740042977
Name:RUSEK, LISA M (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:RUSEK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 DONALDSON AVE
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2322
Mailing Address - Country:US
Mailing Address - Phone:201-317-3588
Mailing Address - Fax:
Practice Address - Street 1:22 DONALDSON AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2322
Practice Address - Country:US
Practice Address - Phone:201-317-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00711000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist