Basic Information
| Provider Information | |||||||||
| NPI: | 1093725061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MISCHELLE | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 466A EASTERN PLAZA SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378213108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236239997 | ||||||||
| FaxNumber: | 4236239909 | ||||||||
| Practice Location | |||||||||
| Address1: | 466A EASTERN PLAZA SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378213108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236239997 | ||||||||
| FaxNumber: | 4236239909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 0000001620 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0100 | 01 | TN | JOHN DEERE TNCARE | OTHER | 4106191 | 01 | TN | BCBS | OTHER | 0103 | 01 | TN | JOHN DEERE TNCARE | OTHER |