Healthcare Provider Details

I. General information

NPI: 1487632758
Provider Name (Legal Business Name): LISA ROTHBERGER SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA TRAVIESA SLP

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

842 N HIGHLAND AVE NE SUITE 275
ATLANTA GA
30306-4530
US

IV. Provider business mailing address

6627 GUNSTOCK LN
TUCKER GA
30084-1436
US

V. Phone/Fax

Practice location:
  • Phone: 404-575-4000
  • Fax: 404-575-4010
Mailing address:
  • Phone: 404-575-4000
  • Fax: 404-575-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP004187
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: