Provider Demographics
NPI:1679083612
Name:CRUZ-WALSH, LISA (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:CRUZ-WALSH
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 1:1301 W COSSITT AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2145
Mailing Address - Country:US
Mailing Address - Phone:708-354-5730
Mailing Address - Fax:
Practice Address - Street 1:1301 W COSSITT AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2145
Practice Address - Country:US
Practice Address - Phone:708-354-5730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005404235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist