Provider Demographics
NPI:1568827723
Name:LIVELY, LESLIE CLARK (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:CLARK
Last Name:LIVELY
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 W SAVANNAH RIDGE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 W. SAVANNAH RIDGE ROAD
Practice Address - Street 2:SUITE 111
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540
Practice Address - Country:US
Practice Address - Phone:504-356-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3615235Z00000X
CA23594235Z00000X
GASLP008998235Z00000X
NC11605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist