Provider Demographics
NPI:1821423625
Name:WHITESIDE, LELA SAMANTHA (MS,CFY-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LELA
Middle Name:SAMANTHA
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:MS,CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10618 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1802
Mailing Address - Country:US
Mailing Address - Phone:501-217-8600
Mailing Address - Fax:501-217-8636
Practice Address - Street 1:10618 BRECKENRIDGE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1802
Practice Address - Country:US
Practice Address - Phone:501-217-8600
Practice Address - Fax:501-217-8636
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8707235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSP#P8707OtherARKANSAS STATE LICENSE