Provider Demographics
NPI:1811264914
Name:BAXTER, LISA DIANE
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:DIANE
Last Name:BAXTER
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 1:106 CEDAR GROVE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-8146
Mailing Address - Country:US
Mailing Address - Phone:843-568-3946
Mailing Address - Fax:843-552-5122
Practice Address - Street 1:350 E WASHINGTON ST UNIT C
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-3982
Practice Address - Country:US
Practice Address - Phone:843-419-7576
Practice Address - Fax:843-552-5122
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC969235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist