Provider Demographics
NPI:1760708374
Name:WHITE, LISA T (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:T
Last Name:WHITE
Suffix:
Gender:
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2899
Mailing Address - Country:US
Mailing Address - Phone:864-522-8611
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B400
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6306
Practice Address - Country:US
Practice Address - Phone:864-454-4368
Practice Address - Fax:864-241-9232
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4227235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1083Medicaid