Provider Demographics
NPI:1699901637
Name:CRAVEN, LISANNE SIMMS (MS)
Entity type:Individual
Prefix:MS
First Name:LISANNE
Middle Name:SIMMS
Last Name:CRAVEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 STRATHMOOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2528
Mailing Address - Country:US
Mailing Address - Phone:502-893-1285
Mailing Address - Fax:
Practice Address - Street 1:9931 FOREST GREEN BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5123
Practice Address - Country:US
Practice Address - Phone:502-588-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100321590Medicaid