Provider Demographics
NPI:1750807004
Name:VENZON, LISA RENEE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:VENZON
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 1:304 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-8533
Mailing Address - Country:US
Mailing Address - Phone:309-256-5752
Mailing Address - Fax:
Practice Address - Street 1:1854 E BROADWAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6664
Practice Address - Country:US
Practice Address - Phone:618-474-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist