=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205117264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA ROY M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2011
-----------------------------------------------------
Last Update Date | 11/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42 HILLER RD
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02770-4023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-763-5896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 533 MIDDLE RD
-----------------------------------------------------
City | ACUSHNET
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02743-1944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-995-3460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 4000
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------