Provider Demographics
NPI:1669006037
Name:WOLFMAN, LISA HER (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:HER
Last Name:WOLFMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 BRINGHURST LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1370
Mailing Address - Country:US
Mailing Address - Phone:916-708-5141
Mailing Address - Fax:
Practice Address - Street 1:1680 E ROSEVILLE PKWY STE 112
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:916-784-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26131235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist