Provider Demographics
NPI:1487750162
Name:MAR, LISA ANN (MS, CCC-A)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MAR
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18502 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-1764
Mailing Address - Country:US
Mailing Address - Phone:402-884-5500
Mailing Address - Fax:
Practice Address - Street 1:1110 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2039
Practice Address - Country:US
Practice Address - Phone:402-228-7329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2008-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE133231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2627462OtherUNITED HEALTHCARE
NE37031OtherBLUECROSS BLUESHIELD
NEF250232OtherMIDLANDS CHOICE
NE10025365400Medicaid
NE10025376600Medicaid
NEF250232OtherMIDLANDS CHOICE