Provider Demographics
NPI:1881975928
Name:FORD, LISA ANNE (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:FORD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:BREGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2118 INWOOD DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7101
Mailing Address - Country:US
Mailing Address - Phone:260-483-9081
Mailing Address - Fax:260-483-9196
Practice Address - Street 1:2118 INWOOD DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7101
Practice Address - Country:US
Practice Address - Phone:260-483-9081
Practice Address - Fax:260-483-9196
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004887A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist