Provider Demographics
NPI:1174906812
Name:WICKLIFFE, LAUREN LEA (MSP, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:LEA
Last Name:WICKLIFFE
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:CATHERINE
Other - Last Name:LEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSP, CCC-SLP
Mailing Address - Street 1:23 ROCK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-1123
Mailing Address - Country:US
Mailing Address - Phone:864-918-3195
Mailing Address - Fax:
Practice Address - Street 1:23 ROCK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-1123
Practice Address - Country:US
Practice Address - Phone:864-918-3195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1567Medicaid