Provider Demographics
NPI:1962428680
Name:DOMINESEY, LISA BYLER (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BYLER
Last Name:DOMINESEY
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 CAPSTONE LN
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5367
Mailing Address - Country:US
Mailing Address - Phone:864-680-2459
Mailing Address - Fax:
Practice Address - Street 1:366 CAPSTONE LN
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5367
Practice Address - Country:US
Practice Address - Phone:864-680-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0667Medicaid