Provider Demographics
NPI:1730331828
Name:LONG, LISA SHERI (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SHERI
Last Name:LONG
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 1:5 SETTLERS RDG S
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3755
Mailing Address - Country:US
Mailing Address - Phone:518-884-0331
Mailing Address - Fax:
Practice Address - Street 1:5 SETTLERS RDG S
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-3755
Practice Address - Country:US
Practice Address - Phone:518-884-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014468-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist