Provider Demographics
NPI:1477755189
Name:TRUESDALE, LAKISHA LATHAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAKISHA
Middle Name:LATHAN
Last Name:TRUESDALE
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 2795
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29721-2795
Mailing Address - Country:US
Mailing Address - Phone:803-283-4445
Mailing Address - Fax:803-339-4094
Practice Address - Street 1:304 NORTH WHITE STREET
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2167
Practice Address - Country:US
Practice Address - Phone:803-283-6318
Practice Address - Fax:803-753-9162
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6556235Z00000X
SC3686235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412209Medicaid
SCSA0607Medicaid