Provider Demographics
NPI:1790917425
Name:RUPERT, LEZLE CHURCH (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LEZLE
Middle Name:CHURCH
Last Name:RUPERT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:LEZLE
Other - Middle Name:BONITA
Other - Last Name:RUPERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:500 TIGER BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4208
Mailing Address - Country:US
Mailing Address - Phone:479-254-5065
Mailing Address - Fax:
Practice Address - Street 1:2 BLOWING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3552
Practice Address - Country:US
Practice Address - Phone:479-696-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist