Provider Demographics
NPI:1285754051
Name:BRODJIESKI, LISA ANN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BRODJIESKI
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 1:301 EDGEMERE DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-3914
Mailing Address - Country:US
Mailing Address - Phone:410-877-4634
Mailing Address - Fax:
Practice Address - Street 1:9145 GUILFORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1883
Practice Address - Country:US
Practice Address - Phone:410-880-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06107235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist