Provider Demographics
NPI:1417025099
Name:FLOYD, LISA ALTAVIA (SPEECH-LANGUAGE PATH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ALTAVIA
Last Name:FLOYD
Suffix:
Gender:F
Credentials:SPEECH-LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 410842
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28241-0842
Mailing Address - Country:US
Mailing Address - Phone:704-583-2389
Mailing Address - Fax:704-583-2389
Practice Address - Street 1:13634 ROYALWOOD LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4716
Practice Address - Country:US
Practice Address - Phone:704-583-2389
Practice Address - Fax:704-583-2389
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3679235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7432970Medicaid