Provider Demographics
NPI:1669477733
Name:BURDGE, LISA C (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:BURDGE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 GEORGE HAYES RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-8493
Mailing Address - Country:US
Mailing Address - Phone:828-757-6226
Mailing Address - Fax:828-757-6289
Practice Address - Street 1:1031 MORGANTON BLVD SW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5677
Practice Address - Country:US
Practice Address - Phone:828-757-6226
Practice Address - Fax:828-757-6289
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3123235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7419914Medicaid
NC19914OtherNC BCBS