Provider Demographics
NPI:1275687667
Name:NELSON, LISA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NELSON
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 1:1538 MERIT LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2098
Mailing Address - Country:US
Mailing Address - Phone:816-210-7963
Mailing Address - Fax:816-792-2362
Practice Address - Street 1:1538 MERIT LN
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2098
Practice Address - Country:US
Practice Address - Phone:816-210-7963
Practice Address - Fax:816-792-2362
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOHE 117116235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist