MEDICARE: MRS. LISA PIETIG SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7207	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46-00576	OTHER	MN	MEDICA
2	HP44286	OTHER	MN	HEALTHPARTNERS
3	319J4MO	OTHER	MN	BCBS-MINNESOTA

General Provider Information

NPI Number	:	1417066630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA PIETIG SLP

Provider Business Mailing Address
First Line	:	223 SHAMROCK DR
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-1760
Country	:	US
Telephone Number	:	612-239-0707
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 SHAMROCK DR
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-1760
Country	:	US
Telephone Number	:	612-239-0707
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	05/01/2009

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