Provider Demographics
NPI:1548523228
Name:BRAGG, LISA ELIZABETH (AUD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ELIZABETH
Last Name:BRAGG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ELIZABETH
Other - Last Name:DAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:3290 N RIDGE ROAD SUITE 125
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3656
Mailing Address - Country:US
Mailing Address - Phone:410-696-2890
Mailing Address - Fax:410-696-2886
Practice Address - Street 1:3290 N RIDGE ROAD SUITE 125
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6017
Practice Address - Country:US
Practice Address - Phone:410-696-2890
Practice Address - Fax:410-696-2886
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01253231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist