Provider Demographics
NPI:1972847192
Name:IVANOV, LISA KNIERIM (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KNIERIM
Last Name:IVANOV
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 1:24476 RIPPLE CT
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-5503
Mailing Address - Country:US
Mailing Address - Phone:904-703-9310
Mailing Address - Fax:
Practice Address - Street 1:8575 RIXLEW LN
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3701
Practice Address - Country:US
Practice Address - Phone:703-257-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist