Provider Demographics
NPI:1013193820
Name:DESHIELDS BOYKIN, GENEA DESHIELDS (MSP CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:GENEA
Middle Name:DESHIELDS
Last Name:DESHIELDS BOYKIN
Suffix:
Gender:F
Credentials:MSP CCC SLP
Other - Prefix:MS
Other - First Name:GENEA
Other - Middle Name:OLISHA
Other - Last Name:DESHIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:355 RIDGE RUN TRAIL
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063
Mailing Address - Country:US
Mailing Address - Phone:803-271-2364
Mailing Address - Fax:803-708-5618
Practice Address - Street 1:355 RIDGE RUN TRAIL
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-271-2364
Practice Address - Fax:803-708-5618
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist