Healthcare Provider Details

I. General information

NPI: 1760494793
Provider Name (Legal Business Name): LISA G VANWIEREN M.ED., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 UNITED FOUNDERS BLVD STE 113G
OKLAHOMA CITY OK
73112-3931
US

IV. Provider business mailing address

3000 UNITED FOUNDERS BLVD STE 113G
OKLAHOMA CITY OK
73112-3931
US

V. Phone/Fax

Practice location:
  • Phone: 405-840-1335
  • Fax: 405-840-1336
Mailing address:
  • Phone: 405-840-1335
  • Fax: 405-840-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number2084
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: