Provider Demographics
NPI:1528608064
Name:AHN, LISA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AHN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 BELA WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1215
Mailing Address - Country:US
Mailing Address - Phone:808-779-8701
Mailing Address - Fax:
Practice Address - Street 1:11151 SUN CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6194
Practice Address - Country:US
Practice Address - Phone:916-273-3389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21344235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist