Healthcare Provider Details

I. General information

NPI: 1023158086
Provider Name (Legal Business Name): MARY LISA MILLBOURN M.A., CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5661 RAND BOULEVARD
SARASOTA FL
34238
US

IV. Provider business mailing address

4521 COCOANUT AVE
SARASOTA FL
34234-4658
US

V. Phone/Fax

Practice location:
  • Phone: 941-927-8805
  • Fax:
Mailing address:
  • Phone: 941-351-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA3169
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: