MEDICARE: MRS. LISA MICHELLE CASSIDY STULTZ MS CCCSLP

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	22004181A	IN

General Provider Information

NPI Number	:	1568651107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MICHELLE CASSIDY STULTZ MS CCCSLP

Provider Business Mailing Address
First Line	:	18 ESTATE DR
Second Line	:
City	:	MOORESVILLE
State	:	IN
Zip	:	46158-1216
Country	:	US
Telephone Number	:	317-374-6947
Fax Number	:

Provider Business Practice Location Address
First Line	:	2141 N DAN JONES RD
Second Line	:
City	:	AVON
State	:	IN
Zip	:	46123-6023
Country	:	US
Telephone Number	:	317-943-1837
Fax Number	:	317-780-3750

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

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	12/06/2022

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