Provider Demographics
NPI:1194789719
Name:GOLDBERG, LISA RAKUSIN (CCC-A)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RAKUSIN
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:SHELI
Other - Last Name:RAKUSIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3705 MEDICAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1027
Mailing Address - Country:US
Mailing Address - Phone:512-452-0231
Mailing Address - Fax:512-454-6019
Practice Address - Street 1:3705 MEDICAL PKWY STE 320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1023
Practice Address - Country:US
Practice Address - Phone:512-454-0392
Practice Address - Fax:512-454-6019
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80073231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L2645Medicare PIN