MEDICARE: LISA RAE O'HANLAN M.ED CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA4734	FL

General Provider Information

NPI Number	:	1063558187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA RAE O'HANLAN M.ED CCC-SLP

Provider Business Mailing Address
First Line	:	1317 DOROTHY DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33764-3657
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 E BAY DR
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33771-2208
Country	:	US
Telephone Number	:	727-582-9665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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