Provider Demographics
NPI:1225606502
Name:NELSON, LISA ROEBUCK (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ROEBUCK
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:118 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1766
Mailing Address - Country:US
Mailing Address - Phone:318-245-8422
Mailing Address - Fax:
Practice Address - Street 1:1601 BITTERSWEET AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2098
Practice Address - Country:US
Practice Address - Phone:318-255-5724
Practice Address - Fax:318-255-5744
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist