Provider Demographics
NPI:1811025422
Name:TANNEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TANNEN
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 1:10001 COORS BYP NW
Mailing Address - Street 2:#227
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4024
Mailing Address - Country:US
Mailing Address - Phone:505-803-2072
Mailing Address - Fax:505-287-8487
Practice Address - Street 1:10001 COORS BYP NW
Practice Address - Street 2:#227
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4024
Practice Address - Country:US
Practice Address - Phone:505-803-2072
Practice Address - Fax:505-287-8487
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM305008235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ7106Medicaid