Provider Demographics
NPI:1932262425
Name:REEVES, LISA M (MSP CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:REEVES
Suffix:
Gender:F
Credentials:MSP CCC-SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:PARDUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSP CCC-SLP
Mailing Address - Street 1:1004 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-3076
Mailing Address - Country:US
Mailing Address - Phone:803-443-8532
Mailing Address - Fax:
Practice Address - Street 1:1004 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3076
Practice Address - Country:US
Practice Address - Phone:803-443-8532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005773235Z00000X
SC3446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA814456023AMedicaid
SC814456023AMedicaid