Provider Demographics
NPI:1831141605
Name:SMITH, LISA COLE (MACCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:COLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4924 GRINNELL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3104
Mailing Address - Country:US
Mailing Address - Phone:919-796-2833
Mailing Address - Fax:
Practice Address - Street 1:4328 BLAND RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6125
Practice Address - Country:US
Practice Address - Phone:919-981-6588
Practice Address - Fax:919-981-6255
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3874235Z00000X
231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211627Medicaid
NC138GXOtherBLUE CROSS BLUE SHEILD #