Provider Demographics
NPI:1205224904
Name:SELF EMPLOYED
Entity Type:Organization
Organization Name:SELF EMPLOYED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST,
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEZLI
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP, MED
Authorized Official - Phone:913-484-7194
Mailing Address - Street 1:11608 W 101ST TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-2710
Mailing Address - Country:US
Mailing Address - Phone:913-484-7194
Mailing Address - Fax:
Practice Address - Street 1:11608 W 101ST TER
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-2710
Practice Address - Country:US
Practice Address - Phone:913-484-7194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2319235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty