Provider Demographics
NPI:1508235854
Name:BELLAVIA, LISA (SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BELLAVIA
Suffix:
Gender:F
Credentials: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 3045
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29578-3045
Mailing Address - Country:US
Mailing Address - Phone:843-855-2333
Mailing Address - Fax:843-903-5541
Practice Address - Street 1:5341 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5074
Practice Address - Country:US
Practice Address - Phone:843-855-2333
Practice Address - Fax:843-903-5541
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist