Provider Demographics
NPI:1396983144
Name:WADE, LISA D (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:WADE
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 1:368 W PIKE ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3240
Mailing Address - Country:US
Mailing Address - Phone:770-755-5278
Mailing Address - Fax:770-755-5682
Practice Address - Street 1:368 W PIKE ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3240
Practice Address - Country:US
Practice Address - Phone:770-755-5278
Practice Address - Fax:770-755-5682
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001688235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist