Provider Demographics
NPI:1427279033
Name:REISS, ELIZABETH D (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:D
Last Name:REISS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:D
Other - Last Name:REISS WENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1300 BEECHDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6804
Mailing Address - Country:US
Mailing Address - Phone:704-995-6037
Mailing Address - Fax:
Practice Address - Street 1:5151 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270
Practice Address - Country:US
Practice Address - Phone:704-365-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005260235Z00000X
NC6524235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist