Provider Demographics
NPI:1295150027
Name:BRACKMANN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRACKMANN
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 1:11150 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2623
Mailing Address - Country:US
Mailing Address - Phone:513-864-2672
Mailing Address - Fax:
Practice Address - Street 1:11150 MAPLE AVENUE
Practice Address - Street 2:CINCINNATI
Practice Address - City:OHIO
Practice Address - State:OH
Practice Address - Zip Code:45241
Practice Address - Country:US
Practice Address - Phone:513-864-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.6814235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist