Provider Demographics
NPI:1225860901
Name:DEFELICE, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:DEFELICE
Suffix:
Gender:F
Credentials:
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 749
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-0749
Mailing Address - Country:US
Mailing Address - Phone:704-869-2088
Mailing Address - Fax:980-288-4239
Practice Address - Street 1:420 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2404
Practice Address - Country:US
Practice Address - Phone:704-706-2200
Practice Address - Fax:980-334-2110
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30003157235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist