MEDICARE: MRS. LISA JANINE THOMAS MS 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	SA10007	FL

General Provider Information

NPI Number	:	1497984520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA JANINE THOMAS MS CCC-SLP

Provider Business Mailing Address
First Line	:	1360 LAKE BALDWIN LN APT C
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-6664
Country	:	US
Telephone Number	:	561-670-9647
Fax Number	:

Provider Business Practice Location Address
First Line	:	1360 LAKE BALDWIN LN APT C
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32814-6664
Country	:	US
Telephone Number	:	561-670-9647
Fax Number	:

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

Provider Enumeration Date	:	07/10/2009
Last Update Date	:	07/10/2009

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