Healthcare Provider Details

I. General information

NPI: 1689845109
Provider Name (Legal Business Name): LISA MARIE GUM MS,CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE HOSFELD MS,CCC/SLP

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
SUFFOLK VA
23434-4529
US

IV. Provider business mailing address

100 N MAIN ST
SUFFOLK VA
23434-4529
US

V. Phone/Fax

Practice location:
  • Phone: 757-925-6764
  • Fax:
Mailing address:
  • Phone: 757-925-6764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: