Provider Demographics
NPI:1801775333
Name:PEDERSON, LISA (SLPA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10655 LEMON AVE APT 1401
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-6958
Mailing Address - Country:US
Mailing Address - Phone:909-519-6787
Mailing Address - Fax:
Practice Address - Street 1:418 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3552
Practice Address - Country:US
Practice Address - Phone:909-373-1641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-28
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20962355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant