Provider Demographics
NPI:1114043155
Name:MANES, LISA M (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MANES
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4259 S ALEXA CIR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-7635
Mailing Address - Country:US
Mailing Address - Phone:907-746-4237
Mailing Address - Fax:
Practice Address - Street 1:109 MAPLE SHADE RD # 303
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-4728
Practice Address - Country:US
Practice Address - Phone:479-420-0817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2350235Z00000X
AK212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156334721Medicaid
AK40381Medicaid