Provider Demographics
NPI:1689845109
Name:GUM, LISA MARIE (MS,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GUM
Suffix:
Gender:F
Credentials:MS,CCC/SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:HOSFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC/SLP
Mailing Address - Street 1:100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4529
Mailing Address - Country:US
Mailing Address - Phone:757-925-6764
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4529
Practice Address - Country:US
Practice Address - Phone:757-925-6764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
WV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7402343000Medicaid