Provider Demographics
NPI:1134594393
Name:LILES, ANNETTE S (MACCC/SLP)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:S
Last Name:LILES
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:PO BOX 913
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-0913
Mailing Address - Country:US
Mailing Address - Phone:980-328-4255
Mailing Address - Fax:
Practice Address - Street 1:709 NORTHEAST DR
Practice Address - Street 2:UNIT 23
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7430
Practice Address - Country:US
Practice Address - Phone:980-328-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3501235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist