Provider Demographics
NPI:1265665335
Name:PEDIATRIC SPEECH THERAPY SERVICES
Entity Type:Organization
Organization Name:PEDIATRIC SPEECH THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYMAC
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC/SLP
Authorized Official - Phone:803-315-5252
Mailing Address - Street 1:820 KIPLING DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2036
Mailing Address - Country:US
Mailing Address - Phone:803-315-5252
Mailing Address - Fax:803-787-2973
Practice Address - Street 1:820 KIPLING DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2036
Practice Address - Country:US
Practice Address - Phone:803-315-5252
Practice Address - Fax:803-787-2973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3360235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0726Medicaid