Provider Demographics
NPI:1689623860
Name:DELUCA, TINA (MA, CCC-SLP, MED)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:DELUCA
Suffix:
Gender:F
Credentials:MA, CCC-SLP, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 JOY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3605
Mailing Address - Country:US
Mailing Address - Phone:843-766-6753
Mailing Address - Fax:843-766-1430
Practice Address - Street 1:1407 JOY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3605
Practice Address - Country:US
Practice Address - Phone:843-766-6753
Practice Address - Fax:843-766-1430
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3225235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0462Medicaid