Provider Demographics
NPI:1518093632
Name:IDEAL INTERVENTION, LLC
Entity Type:Organization
Organization Name:IDEAL INTERVENTION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:SLICE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MSP, CCC-SLP, BCABA
Authorized Official - Phone:803-360-2978
Mailing Address - Street 1:124 BAILEY SLICE RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8900
Mailing Address - Country:US
Mailing Address - Phone:803-360-2978
Mailing Address - Fax:803-932-7897
Practice Address - Street 1:124 BAILEY SLICE RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8900
Practice Address - Country:US
Practice Address - Phone:803-360-2978
Practice Address - Fax:803-932-7897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0289Medicaid