Provider Demographics
NPI:1184865024
Name:SMITH, LISA CLARK (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CLARK
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SHADOWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1914
Mailing Address - Country:US
Mailing Address - Phone:864-653-9757
Mailing Address - Fax:
Practice Address - Street 1:108 SHADOWOOD RD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1914
Practice Address - Country:US
Practice Address - Phone:864-653-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2264235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSAO659Medicaid