Provider Demographics
NPI:1558738062
Name:WILLIAMS, LISA (M ED CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:M ED CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PEARL AVE N
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-4632
Mailing Address - Country:US
Mailing Address - Phone:912-331-0846
Mailing Address - Fax:678-792-4894
Practice Address - Street 1:618 BOWENS MILL RD SW
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3926
Practice Address - Country:US
Practice Address - Phone:912-331-0846
Practice Address - Fax:678-792-4894
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008831235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003171926BMedicaid