Provider Demographics
NPI:1417312141
Name:IMAN, LISA ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:IMAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 CLEARBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-5901
Mailing Address - Country:US
Mailing Address - Phone:757-839-2884
Mailing Address - Fax:
Practice Address - Street 1:18676 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-4049
Practice Address - Country:US
Practice Address - Phone:910-821-1700
Practice Address - Fax:910-319-9105
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006558235Z00000X
GASLP012723235Z00000X
NC15004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist