Basic Information
| Provider Information | |||||||||
| NPI: | 1023395126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVERCAST | ||||||||
| FirstName: | LISSI | ||||||||
| MiddleName: | WANDEMBURG | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 PERKINS DR STE B | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755266682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1681 HICKORY LOOP | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880056587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756473773 | ||||||||
| FaxNumber: | 5756473777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP5152 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.