MEDICARE: LESLEY VANDYCK MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	14046651	NC

General Provider Information

NPI Number	:	1104216217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLEY VANDYCK MS CCC-SLP

Provider Business Mailing Address
First Line	:	7401 CARMEL EXECUTIVE PARK DR STE 220
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4219
Country	:	US
Telephone Number	:	980-237-3132
Fax Number	:

Provider Business Practice Location Address
First Line	:	7401 CARMEL EXECUTIVE PARK DR STE 220
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4219
Country	:	US
Telephone Number	:	980-237-3132
Fax Number	:	704-457-1097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/30/2023

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