Provider Demographics
NPI:1437598356
Name:HARRISON, MYNITA S (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MYNITA
Middle Name:S
Last Name:HARRISON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2672 BIG BUCK BLVD
Mailing Address - Street 2:
Mailing Address - City:BOWMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29018-9663
Mailing Address - Country:US
Mailing Address - Phone:803-539-0380
Mailing Address - Fax:
Practice Address - Street 1:2672 BIG BUCK BLVD
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:SC
Practice Address - Zip Code:29018-9663
Practice Address - Country:US
Practice Address - Phone:803-539-0380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist