MEDICARE: LISA LILTZ CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	21223	CA

General Provider Information

NPI Number	:	1740799626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA LILTZ CCC-SLP

Provider Business Mailing Address
First Line	:	310 LAKE ST UNIT 109
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-5822
Country	:	US
Telephone Number	:	617-596-2233
Fax Number	:

Provider Business Practice Location Address
First Line	:	774 S PLACENTIA AVE STE 200
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-6838
Country	:	US
Telephone Number	:	800-870-7989
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2017
Last Update Date	:	09/24/2017

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