Provider Demographics
NPI:1710588942
Name:SOUTHERN OAKS THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHERN OAKS THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:F
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:803-943-6401
Mailing Address - Street 1:1460 POCOTALIGO RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-6826
Mailing Address - Country:US
Mailing Address - Phone:803-943-6401
Mailing Address - Fax:
Practice Address - Street 1:1460 POCOTALIGO RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-6826
Practice Address - Country:US
Practice Address - Phone:803-943-6401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty