Provider Demographics
NPI:1811293475
Name:LISA WAGNER
Entity type:Organization
Organization Name:LISA WAGNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-A
Authorized Official - Phone:517-336-1940
Mailing Address - Street 1:4970 NORTHWIND DR
Mailing Address - Street 2:SUITE 226
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5080
Mailing Address - Country:US
Mailing Address - Phone:517-336-1940
Mailing Address - Fax:517-336-1944
Practice Address - Street 1:455 E GRAND RIVER AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1551
Practice Address - Country:US
Practice Address - Phone:810-494-1700
Practice Address - Fax:810-494-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000283231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty