Healthcare Provider Details

I. General information

NPI: 1225856891
Provider Name (Legal Business Name): NAN LYU CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NAN LU

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 BICKFORD ST
JAMAICA PLAIN MA
02130-1401
US

IV. Provider business mailing address

11 HAWTHORNE ST
BELMONT MA
02478-1950
US

V. Phone/Fax

Practice location:
  • Phone: 617-971-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP100693
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: