Provider Demographics
NPI:1649412123
Name:MCDILDA, DALZELL GINN (MEDCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DALZELL
Middle Name:GINN
Last Name:MCDILDA
Suffix:
Gender:F
Credentials:MEDCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 BLACK RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-3304
Mailing Address - Country:US
Mailing Address - Phone:843-651-1938
Mailing Address - Fax:843-651-3669
Practice Address - Street 1:606 BLACK RIVER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3304
Practice Address - Country:US
Practice Address - Phone:843-651-1938
Practice Address - Fax:843-651-3669
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2238235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2238OtherSPEECH-LANGUAGE PATHOLOGIST LICENSE