Healthcare Provider Details

I. General information

NPI: 1316072903
Provider Name (Legal Business Name): LISA JEAN WISE MA CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W HIGHWAY 54 VAN-FAR R-1 SCHOOL DISTRICT
VANDALIA MO
63382-1130
US

IV. Provider business mailing address

4398 HIGHWAY W
VANDALIA MO
63382-4408
US

V. Phone/Fax

Practice location:
  • Phone: 573-594-6111
  • Fax: 573-594-2878
Mailing address:
  • Phone: 573-721-5568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2002013175
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: