Provider Demographics
NPI:1023395126
Name:OVERCAST, LISSI WANDEMBURG (MA)
Entity Type:Individual
Prefix:
First Name:LISSI
Middle Name:WANDEMBURG
Last Name:OVERCAST
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PERKINS DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3248
Mailing Address - Country:US
Mailing Address - Phone:575-526-6682
Mailing Address - Fax:
Practice Address - Street 1:1681 HICKORY LOOP
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-6587
Practice Address - Country:US
Practice Address - Phone:575-647-3773
Practice Address - Fax:575-647-3777
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLP5152235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist