Provider Demographics
NPI:1306916564
Name:DAVIS, LISA M
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:DAVIS
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 1:22 DEPOT ST
Mailing Address - Street 2:ST LAWRENCE CO NYSARC POTSDAM DAY HABILITATION
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-268-1003
Mailing Address - Fax:315-268-0908
Practice Address - Street 1:22 DEPOT ST
Practice Address - Street 2:ST LAWRENCE CO NYSARC POTSDAM DAY HABILITATION
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676
Practice Address - Country:US
Practice Address - Phone:315-268-1003
Practice Address - Fax:315-268-0908
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006836235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist