Provider Demographics
NPI:1679817225
Name:WAGNER, LISA A (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:BOURGEOIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1500 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3705
Mailing Address - Country:US
Mailing Address - Phone:541-346-2578
Mailing Address - Fax:
Practice Address - Street 1:1500 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3705
Practice Address - Country:US
Practice Address - Phone:541-346-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17560235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist