Provider Demographics
NPI:1356839815
Name:FOSBERRY, REBECCA M
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:FOSBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 OLD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4941
Mailing Address - Country:US
Mailing Address - Phone:843-532-1325
Mailing Address - Fax:
Practice Address - Street 1:1525 OLD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4941
Practice Address - Country:US
Practice Address - Phone:843-532-1325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty