Provider Demographics
NPI:1518485861
Name:HALVERSON, TESS JOELL
Entity Type:Individual
Prefix:
First Name:TESS
Middle Name:JOELL
Last Name:HALVERSON
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 1:650 ENTERPRISE BLVD APT 10202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8555
Mailing Address - Country:US
Mailing Address - Phone:843-569-4546
Mailing Address - Fax:843-569-4535
Practice Address - Street 1:9225 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9149
Practice Address - Country:US
Practice Address - Phone:843-569-4546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA2001Medicaid
14396156OtherCAQH