Provider Demographics
NPI:1487632758
Name:ROTHBERGER, LISA (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROTHBERGER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TRAVIESA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:6627 GUNSTOCK LN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-1436
Mailing Address - Country:US
Mailing Address - Phone:404-575-4000
Mailing Address - Fax:404-575-4010
Practice Address - Street 1:842 N HIGHLAND AVE NE
Practice Address - Street 2:SUITE 275
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4530
Practice Address - Country:US
Practice Address - Phone:404-575-4000
Practice Address - Fax:404-575-4010
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA098232599AMedicaid