Provider Demographics
NPI:1619140456
Name:MARTY, LISA MARLENE (MS CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARLENE
Last Name:MARTY
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 COUNTY ROAD 12 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313
Mailing Address - Country:US
Mailing Address - Phone:763-458-4315
Mailing Address - Fax:763-542-2280
Practice Address - Street 1:2144 COUNTY RD 12 SOUTH
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313
Practice Address - Country:US
Practice Address - Phone:763-458-4315
Practice Address - Fax:763-542-2280
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6288235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN00072LIOtherBCBS
MN4600226OtherMEDICA
MNV411933831110351OtherHEALTH PARTNERS