Provider Demographics
NPI:1427269554
Name:DAVIS, LISA MABRY (MSP, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MABRY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MABRY
Other - Last Name:SEAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSP CCC-SLP
Mailing Address - Street 1:738 N GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29341-5209
Mailing Address - Country:US
Mailing Address - Phone:864-461-5228
Mailing Address - Fax:
Practice Address - Street 1:738 N GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-5209
Practice Address - Country:US
Practice Address - Phone:864-461-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1532235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSAO147Medicaid