Provider Demographics
NPI:1306923990
Name:IRVIN, LISA JANICE (SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JANICE
Last Name:IRVIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N A ST BLDG 1-244
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-5472
Mailing Address - Country:US
Mailing Address - Phone:432-570-4400
Mailing Address - Fax:432-570-4460
Practice Address - Street 1:3300 N A ST BLDG 1-244
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-5472
Practice Address - Country:US
Practice Address - Phone:432-570-4400
Practice Address - Fax:432-570-4460
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14147235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist