Provider Demographics
NPI:1144369414
Name:GUERETTE, LISA MARIE (MA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GUERETTE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2401 E 42ND AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5228
Mailing Address - Country:US
Mailing Address - Phone:907-562-4550
Mailing Address - Fax:907-562-4554
Practice Address - Street 1:2100 W 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1971
Practice Address - Country:US
Practice Address - Phone:213-353-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2947231H00000X
AK30235Z00000X
AK55231H00000X
CA20127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP7673Medicaid
AKAU7673Medicaid