Provider Demographics
NPI:1548380918
Name:OSHER, SERENA VALDIVIESO (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SERENA
Middle Name:VALDIVIESO
Last Name:OSHER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:SERENA
Other - Middle Name:M
Other - Last Name:VALDIVIESO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:1040 PARK MANOR TER NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1455
Mailing Address - Country:US
Mailing Address - Phone:404-290-1960
Mailing Address - Fax:
Practice Address - Street 1:3518 OLD LAMPLIGHTER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-3420
Practice Address - Country:US
Practice Address - Phone:404-909-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006461235Z00000X
SC3582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA596591603AMedicaid