Provider Demographics
NPI:1801255161
Name:BLACK, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLACK
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 1:2355 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4233
Mailing Address - Country:US
Mailing Address - Phone:858-472-3022
Mailing Address - Fax:
Practice Address - Street 1:5400 LAUREL SPRINGS PKWY
Practice Address - Street 2:BLDG 400 #404
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6056
Practice Address - Country:US
Practice Address - Phone:678-473-9954
Practice Address - Fax:678-931-0105
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14052341235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist