Provider Demographics
NPI:1639663685
Name:RUKOVENA, LISA ANNE (MA, CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:RUKOVENA
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 1:4713 BUNDYHILL DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-6130
Mailing Address - Country:US
Mailing Address - Phone:512-228-4884
Mailing Address - Fax:
Practice Address - Street 1:2011 BROADWAY ST STE 130
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5945
Practice Address - Country:US
Practice Address - Phone:281-997-8509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist