Provider Demographics
NPI:1487400727
Name:LISA, GINA MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:LISA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-2920
Mailing Address - Country:US
Mailing Address - Phone:973-868-5610
Mailing Address - Fax:
Practice Address - Street 1:1801 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SCOTCH PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07076-1749
Practice Address - Country:US
Practice Address - Phone:908-312-9476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01224800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist