Provider Demographics
NPI:1508982307
Name:BROGDON, LISA HALES (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:HALES
Last Name:BROGDON
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 1:135 MIDDLECREST WAY
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-9143
Mailing Address - Country:US
Mailing Address - Phone:919-630-9040
Mailing Address - Fax:919-553-3836
Practice Address - Street 1:8031 US BUS HWY 70W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-4807
Practice Address - Country:US
Practice Address - Phone:919-630-9040
Practice Address - Fax:919-553-3836
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3916235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10240OtherBCBS
NC7411112Medicaid