Provider Demographics
NPI:1790039618
Name:STERN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 MARSHALL RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-7364
Mailing Address - Country:US
Mailing Address - Phone:928-814-8900
Mailing Address - Fax:
Practice Address - Street 1:1031 MARSHALL RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-7364
Practice Address - Country:US
Practice Address - Phone:928-814-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12137377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12137377OtherMEDICARE