Healthcare Provider Details

I. General information

NPI: 1639910508
Provider Name (Legal Business Name): LYDIA GOEBEL CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 W CHARLESTON BLVD
LAS VEGAS NV
89146-1139
US

IV. Provider business mailing address

70 TIDWELL LN
HENDERSON NV
89074-3370
US

V. Phone/Fax

Practice location:
  • Phone: 702-259-1903
  • Fax:
Mailing address:
  • Phone: 702-540-4328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-3861
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: