Provider Demographics
NPI:1366164410
Name:VANDEREE, LISA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:VANDEREE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12818 SW SEA GODDESS LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-7772
Mailing Address - Country:US
Mailing Address - Phone:561-371-8112
Mailing Address - Fax:
Practice Address - Street 1:12818 SW SEA GODDESS LN
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-7772
Practice Address - Country:US
Practice Address - Phone:561-371-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2598235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist