=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245422880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA IVEY SLPA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2007
-----------------------------------------------------
Last Update Date | 07/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 GROVE ST
-----------------------------------------------------
City | NORWAY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04268-5610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-739-2242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 GROVE ST
-----------------------------------------------------
City | NORWAY
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04268-5610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-739-2242
-----------------------------------------------------
Fax | 207-739-2466
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | SAS1770
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------