Provider Demographics
NPI:1285855627
Name:PHILLIPS, TABITHA BERRY (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:BERRY
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:203 N MAPLE STREET
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2449
Mailing Address - Country:US
Mailing Address - Phone:864-757-9846
Mailing Address - Fax:864-757-9847
Practice Address - Street 1:203 N MAPLE STREET
Practice Address - Street 2:SUITE 10
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2449
Practice Address - Country:US
Practice Address - Phone:864-757-9846
Practice Address - Fax:864-757-9847
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC2204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0445Medicaid