Provider Demographics
NPI:1073599296
Name:GREENWAY, LISA A (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:GREENWAY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:KONGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:8806 COLDWATER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2715
Mailing Address - Country:US
Mailing Address - Phone:260-482-4327
Mailing Address - Fax:260-482-4320
Practice Address - Street 1:8806 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2715
Practice Address - Country:US
Practice Address - Phone:260-482-4327
Practice Address - Fax:260-482-4320
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002271A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200341310Medicaid
IN200341310Medicaid