Provider Demographics
NPI:1104155472
Name:SANDRE, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SANDRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W THOMAS RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4405
Mailing Address - Country:US
Mailing Address - Phone:602-406-4185
Mailing Address - Fax:602-294-5943
Practice Address - Street 1:124 W THOMAS RD
Practice Address - Street 2:SUITE 130
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4405
Practice Address - Country:US
Practice Address - Phone:602-406-4185
Practice Address - Fax:602-294-5943
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA6450231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter