Provider Demographics
NPI:1073616306
Name:NELSON, LISA LYNN (MA, CCC/SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA, 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:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:MULE CREEK
Mailing Address - State:NM
Mailing Address - Zip Code:88051-0052
Mailing Address - Country:US
Mailing Address - Phone:505-535-2457
Mailing Address - Fax:
Practice Address - Street 1:100 SUNRISE MEADOW ROAD
Practice Address - Street 2:BOX 52
Practice Address - City:MULE CREEK
Practice Address - State:NM
Practice Address - Zip Code:88051-0052
Practice Address - Country:US
Practice Address - Phone:505-535-2457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist