Provider Demographics
NPI:1083849574
Name:LIZAR, DWAYNE (MS)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:LIZAR
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39873 MOUNT BLANC AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4797
Mailing Address - Country:US
Mailing Address - Phone:951-970-1194
Mailing Address - Fax:
Practice Address - Street 1:1740 LA COSTA MEADOWS DR
Practice Address - Street 2:SUITE 144
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-5199
Practice Address - Country:US
Practice Address - Phone:951-970-1194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 648231H00000X
CASP 4188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist