Provider Demographics
NPI:1972738185
Name:DAVIS, LISA MICHELLE (MCD-SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MCD-SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SCOTTS BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-8011
Mailing Address - Country:US
Mailing Address - Phone:864-561-5838
Mailing Address - Fax:855-849-5178
Practice Address - Street 1:118 SCOTTS BLUFF DR
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681
Practice Address - Country:US
Practice Address - Phone:864-561-5838
Practice Address - Fax:855-849-5178
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1007Medicaid