Basic Information
| Provider Information | |||||||||
| NPI: | 1538475009 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SASAKI | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIKO | ||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457229 | ||||||||
| FaxNumber: | 9043457240 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457229 | ||||||||
| FaxNumber: | 9043457240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 03/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1464 | NE | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA11916 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 47065477700 | 05 | NE | MEDICAID |