Provider Demographics
NPI:1962051888
Name:DESAUTELS, LISA BORELLI (SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:BORELLI
Last Name:DESAUTELS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 HAZARDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-3331
Mailing Address - Country:US
Mailing Address - Phone:413-519-2295
Mailing Address - Fax:
Practice Address - Street 1:24 TABOR XING STE D34
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1785
Practice Address - Country:US
Practice Address - Phone:413-567-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4263235Z00000X
MA4263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist