Provider Demographics
NPI:1316072903
Name:WISE, LISA JEAN (MA CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JEAN
Last Name:WISE
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 1:4398 HIGHWAY W
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:63382-4408
Mailing Address - Country:US
Mailing Address - Phone:573-721-5568
Mailing Address - Fax:
Practice Address - Street 1:2200 W HIGHWAY 54
Practice Address - Street 2:VAN-FAR R-1 SCHOOL DISTRICT
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382-1130
Practice Address - Country:US
Practice Address - Phone:573-594-6111
Practice Address - Fax:573-594-2878
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002013175235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO467477907Medicaid