Provider Demographics
NPI:1972049468
Name:GARDNER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GARDNER
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 1:5001 W DOBBINS RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-9733
Mailing Address - Country:US
Mailing Address - Phone:602-237-9100
Mailing Address - Fax:
Practice Address - Street 1:5001 W DOBBINS RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-9733
Practice Address - Country:US
Practice Address - Phone:602-237-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA96992355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant