Provider Demographics
NPI:1255905592
Name:BAMBERGER, LISA C (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:C
Last Name:BAMBERGER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7695 LAVENHAM LNDG
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-3712
Mailing Address - Country:US
Mailing Address - Phone:410-236-5796
Mailing Address - Fax:
Practice Address - Street 1:6929 MATTHEW PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3607
Practice Address - Country:US
Practice Address - Phone:703-813-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005005235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist