Provider Demographics
NPI:1376861179
Name:LONGORIA, LISA (MA, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LONGORIA
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16714 HUNTING VLY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-1056
Mailing Address - Country:US
Mailing Address - Phone:210-626-8993
Mailing Address - Fax:
Practice Address - Street 1:16714 HUNTING VLY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-1056
Practice Address - Country:US
Practice Address - Phone:210-626-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18804235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist