Provider Demographics
NPI:1548362056
Name:BLANTON, LISA RAE (MS/CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RAE
Last Name:BLANTON
Suffix:
Gender:F
Credentials:MS/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:W2579 HALE RD
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:WI
Mailing Address - Zip Code:53059-9522
Mailing Address - Country:US
Mailing Address - Phone:920-625-3147
Mailing Address - Fax:
Practice Address - Street 1:N3995 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9618
Practice Address - Country:US
Practice Address - Phone:920-674-7386
Practice Address - Fax:920-674-6694
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1265-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist