Provider Demographics
NPI:1013418607
Name:MATHIAS, LISA SUZANNE (MS, CCC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUZANNE
Last Name:MATHIAS
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9277 ELK RUN RD
Mailing Address - Street 2:
Mailing Address - City:CATLETT
Mailing Address - State:VA
Mailing Address - Zip Code:20119-2024
Mailing Address - Country:US
Mailing Address - Phone:703-586-7040
Mailing Address - Fax:
Practice Address - Street 1:14715 BRISTOW RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-3945
Practice Address - Country:US
Practice Address - Phone:703-791-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist