Provider Demographics
NPI:1083826838
Name:COULTER, LISA MARIE (MS-CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:COULTER
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS-CCC-SLP
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53006-0094
Mailing Address - Country:US
Mailing Address - Phone:920-583-3923
Mailing Address - Fax:
Practice Address - Street 1:115 E ARNDT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2461
Practice Address - Country:US
Practice Address - Phone:920-923-7054
Practice Address - Fax:920-923-7058
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42714000Medicaid