Provider Demographics
NPI:1144471673
Name:ANDERSON, LISA M (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 LARCHMONT CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7103
Mailing Address - Country:US
Mailing Address - Phone:707-208-7287
Mailing Address - Fax:
Practice Address - Street 1:2034 LARCHMONT CIR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7103
Practice Address - Country:US
Practice Address - Phone:707-208-7287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist