Provider Demographics
NPI:1376608612
Name:SUMMERVILLE SPEECH THERAPY, PA
Entity Type:Organization
Organization Name:SUMMERVILLE SPEECH THERAPY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:843-856-4949
Mailing Address - Street 1:PO BOX 1342
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29484-1342
Mailing Address - Country:US
Mailing Address - Phone:843-856-4949
Mailing Address - Fax:
Practice Address - Street 1:1551 BEN SAWYER BLVD
Practice Address - Street 2:UNIT 1-E
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5500
Practice Address - Country:US
Practice Address - Phone:843-856-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC312235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3442Medicaid