Provider Demographics
NPI:1649318858
Name:BEARD, KIESHA LASHAY (BS SLP)
Entity type:Individual
Prefix:
First Name:KIESHA
Middle Name:LASHAY
Last Name:BEARD
Suffix:
Gender:F
Credentials:BS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4813 W GARY WAY
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2340
Mailing Address - Country:US
Mailing Address - Phone:313-930-1943
Mailing Address - Fax:
Practice Address - Street 1:4813 W GARY WAY
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2340
Practice Address - Country:US
Practice Address - Phone:313-930-1943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ134813Medicaid