Healthcare Provider Details

I. General information

NPI: 1790981736
Provider Name (Legal Business Name): LISA MARIE MACLEOD SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA MEDDAC BAVARIA CMR 411 BLDG 700
APO AE
09112
US

IV. Provider business mailing address

PO BOX 37
FREEDOM NH
03836-0037
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2400
  • Fax:
Mailing address:
  • Phone: 603-539-4134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP1382
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: