Provider Demographics
NPI:1598920696
Name:SPEECH-LANGUAGE PATHWAYS THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:SPEECH-LANGUAGE PATHWAYS THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:803-603-2252
Mailing Address - Street 1:708 FAIRWAY LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5715
Mailing Address - Country:US
Mailing Address - Phone:803-603-2252
Mailing Address - Fax:803-798-2892
Practice Address - Street 1:708 FAIRWAY LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5715
Practice Address - Country:US
Practice Address - Phone:803-603-2252
Practice Address - Fax:803-798-2892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3441235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1922075712Medicaid