Healthcare Provider Details

I. General information

NPI: 1770414674
Provider Name (Legal Business Name): LISA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W230S8695 BIG BEND DR
BIG BEND WI
53103-9202
US

IV. Provider business mailing address

W158S7830 ELLIOTT CT
MUSKEGO WI
53150-8494
US

V. Phone/Fax

Practice location:
  • Phone: 262-393-4401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: