Provider Demographics
NPI:1972759751
Name:BLAIR, LISA ANNETTE (MA, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNETTE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MARINER ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-2030
Mailing Address - Country:US
Mailing Address - Phone:716-883-5350
Mailing Address - Fax:
Practice Address - Street 1:1657 KENSINGTON AVE
Practice Address - Street 2:THE EARLY CHILDHOOD PROGRAM OF WCHOB/K
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1412
Practice Address - Country:US
Practice Address - Phone:716-831-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004318-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist