Provider Demographics
NPI:1033288402
Name:S.C. STATE UNIVERSITY
Entity Type:Organization
Organization Name:S.C. STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-536-7063
Mailing Address - Street 1:300 COLLEGE STREET, NE
Mailing Address - Street 2:P O BOX 7427
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29117-0001
Mailing Address - Country:US
Mailing Address - Phone:803-536-8073
Mailing Address - Fax:803-533-3627
Practice Address - Street 1:300 COLLEGE STREET, NE
Practice Address - Street 2:300 COLLEG STREET, NE
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29117-0001
Practice Address - Country:US
Practice Address - Phone:803-536-8073
Practice Address - Fax:803-533-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC349987Medicaid