Provider Demographics
NPI:1881197176
Name:WATSON, LISA ERVIN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ERVIN
Last Name:WATSON
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 1:1625 HEAD OF RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-1449
Mailing Address - Country:US
Mailing Address - Phone:757-506-5493
Mailing Address - Fax:
Practice Address - Street 1:6016 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3807
Practice Address - Country:US
Practice Address - Phone:757-648-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist