MEDICARE: LISA SIMON MA 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	SP-3195	OH

General Provider Information

NPI Number	:	1588087019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SIMON MA CCC-SLP

Provider Business Mailing Address
First Line	:	1802 ROYCROFT RD
Second Line	:
City	:	HOLLAND
State	:	OH
Zip	:	43528-9612
Country	:	US
Telephone Number	:	419-466-5209
Fax Number	:

Provider Business Practice Location Address
First Line	:	3281 UPTON AVE RM 2226
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43613-5109
Country	:	US
Telephone Number	:	419-671-8724
Fax Number	:

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

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/04/2014

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Directions to “ LISA SIMON MA CCC-SLP” Practice Location

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