Provider Demographics
NPI:1720126428
Name:AMAVISCA, LISA (MS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:AMAVISCA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 LEONOR DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2801
Mailing Address - Country:US
Mailing Address - Phone:916-359-2752
Mailing Address - Fax:
Practice Address - Street 1:750 F ST STE 2
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3738
Practice Address - Country:US
Practice Address - Phone:530-758-8944
Practice Address - Fax:530-758-4302
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE4222235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist