Provider Demographics
NPI:1679697692
Name:HERNANDEZ, LISETTE (SLP)
Entity type:Individual
Prefix:
First Name:LISETTE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 ALCOVY ST
Mailing Address - Street 2:SUITE G-1, P.O. BOX 1250
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2183
Mailing Address - Country:US
Mailing Address - Phone:770-207-9043
Mailing Address - Fax:770-207-9029
Practice Address - Street 1:226 ALCOVY ST
Practice Address - Street 2:SUITE G-1
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2183
Practice Address - Country:US
Practice Address - Phone:770-207-9043
Practice Address - Fax:770-207-9029
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005291235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist