Provider Demographics
NPI:1164169470
Name:LEA, CHIQUEETA
Entity Type:Individual
Prefix:
First Name:CHIQUEETA
Middle Name:
Last Name:LEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 MILTON RD STE F
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5079
Mailing Address - Country:US
Mailing Address - Phone:704-258-8951
Mailing Address - Fax:980-237-6226
Practice Address - Street 1:3116 MILTON RD STE F
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5079
Practice Address - Country:US
Practice Address - Phone:704-258-8951
Practice Address - Fax:980-237-6288
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1003940933OtherGROUP NPI