Provider Demographics
NPI:1275218570
Name:SOURWINE, OLIVIA ANN (MA CF-SLP)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ANN
Last Name:SOURWINE
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8703 HIGHWAY 17 BYP S STE I
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-7701
Mailing Address - Country:US
Mailing Address - Phone:843-457-1053
Mailing Address - Fax:843-215-2910
Practice Address - Street 1:8703 HIGHWAY 17 BYP S STE I
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-7701
Practice Address - Country:US
Practice Address - Phone:843-457-1053
Practice Address - Fax:843-215-2910
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist