Provider Demographics
NPI:1619408820
Name:SALDIVAR MIMS, CHRISTA DANIELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTA
Middle Name:DANIELLE
Last Name:SALDIVAR MIMS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:CHRISTA
Other - Middle Name:DANIELLE
Other - Last Name:NETTLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:318 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2116
Mailing Address - Country:US
Mailing Address - Phone:843-374-2221
Mailing Address - Fax:
Practice Address - Street 1:318 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2116
Practice Address - Country:US
Practice Address - Phone:843-374-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist