Provider Demographics
NPI:1316400120
Name:WIERSMA, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WIERSMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 E BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5906
Mailing Address - Country:US
Mailing Address - Phone:616-831-8643
Mailing Address - Fax:616-949-8421
Practice Address - Street 1:2320 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5906
Practice Address - Country:US
Practice Address - Phone:616-831-8643
Practice Address - Fax:616-949-8421
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist