Provider Demographics
NPI:1760494793
Name:VANWIEREN, LISA G (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:G
Last Name:VANWIEREN
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 UNITED FOUNDERS BLVD STE 113G
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3931
Mailing Address - Country:US
Mailing Address - Phone:405-840-1335
Mailing Address - Fax:405-840-1336
Practice Address - Street 1:3000 UNITED FOUNDERS BLVD STE 113G
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3931
Practice Address - Country:US
Practice Address - Phone:405-840-1335
Practice Address - Fax:405-840-1336
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100656080AMedicaid