Provider Demographics
NPI:1700461589
Name:RETTBERG, LISA ANN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:RETTBERG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9438 LEDIG DR
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-4926
Mailing Address - Country:US
Mailing Address - Phone:951-295-9320
Mailing Address - Fax:
Practice Address - Street 1:9438 LEDIG DR
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-4926
Practice Address - Country:US
Practice Address - Phone:951-295-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP9860235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty