Provider Demographics
NPI:1013052000
Name:TATE, LISA A
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:TATE
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 1:1611 HEADWAY CIR BLDG 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-5165
Mailing Address - Country:US
Mailing Address - Phone:512-478-2581
Mailing Address - Fax:512-476-1638
Practice Address - Street 1:1611 HEADWAY CIR BLDG 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-5165
Practice Address - Country:US
Practice Address - Phone:512-478-2581
Practice Address - Fax:512-476-1638
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18507235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126129901Medicaid
TX021286201Medicaid
TX89695TOtherBLUE CROSS