Healthcare Provider Details

I. General information

NPI: 1700912847
Provider Name (Legal Business Name): LISA SQUADRITO M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2007
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17122 LYNN LN APT C
HUNTINGTN BCH CA
92649-4347
US

IV. Provider business mailing address

17122 LYNN LN APT C
HUNTINGTN BCH CA
92649-4347
US

V. Phone/Fax

Practice location:
  • Phone: 206-940-7013
  • Fax:
Mailing address:
  • Phone: 206-940-7013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL00003737
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number21638
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: