Provider Demographics
NPI:1306268974
Name:HAKES, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HAKES
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 1:61 BARRETTS AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2114
Mailing Address - Country:US
Mailing Address - Phone:631-730-8921
Mailing Address - Fax:
Practice Address - Street 1:58 MAYTIME DR
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2200
Practice Address - Country:US
Practice Address - Phone:516-203-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013665-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist