Provider Demographics
NPI:1871767442
Name:CONKLYN, LISA MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:CONKLYN
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 1:5722 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4124
Mailing Address - Country:US
Mailing Address - Phone:262-652-6486
Mailing Address - Fax:
Practice Address - Street 1:5722 35TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4124
Practice Address - Country:US
Practice Address - Phone:262-652-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2382-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42798400Medicaid