Provider Demographics
NPI:1275863334
Name:BERG, LISA A (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:BERG
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 W SWEETWATER AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1505
Mailing Address - Country:US
Mailing Address - Phone:602-347-2653
Mailing Address - Fax:602-347-2709
Practice Address - Street 1:4650 W SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1505
Practice Address - Country:US
Practice Address - Phone:602-347-2653
Practice Address - Fax:602-347-2709
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA63802355S0801X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant