Provider Demographics
NPI:1417066630
Name:PIETIG, LISA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:PIETIG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 SHAMROCK DR
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1760
Mailing Address - Country:US
Mailing Address - Phone:612-239-0707
Mailing Address - Fax:
Practice Address - Street 1:223 SHAMROCK DR
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1760
Practice Address - Country:US
Practice Address - Phone:612-239-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7207235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN46-00576OtherMEDICA
MNHP44286OtherHEALTHPARTNERS
MN319J4MOOtherBCBS-MINNESOTA