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General NPI Number Information
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NPI Number | 1346541661
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Entity Type | Individual
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Provider Name | LISA WADE MS, CCC/SLP
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Gender | Female
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Dates
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Enumeration Date | 11/03/2010
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Last Update Date | 11/03/2010
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Provider Practice Location Address
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Address Line | 650 N JEFFERSON ST
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City | ROANOKE
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State | VA
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Zip | 24016-1427
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Country | US
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Telephone | 540-904-6718
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Fax |
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Provider Business Mailing Address
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Address Line | 2174 STONE MILL DR
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City | SALEM
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State | VA
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Zip | 24153-4667
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2202002558
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License Number State | VA
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