Provider Demographics
NPI:1326141730
Name:YOUNG, LISA MARIE (MACCCA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MACCCA
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:ROMMELFANGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CFYA
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:303-776-1234
Mailing Address - Fax:720-494-3107
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:303-776-1234
Practice Address - Fax:720-494-3107
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO297231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO39439534Medicaid
CO345519YLB8Medicare PIN