Basic Information
| Provider Information | |||||||||
| NPI: | 1528458353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARKSDALE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE # 4THFL | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 PATEWOOD DR | ||||||||
| Address2: | SUITE B400 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644544368 | ||||||||
| FaxNumber: | 8642419232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5664 | SC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | SA1528 | 05 | SC | MEDICAID |