Provider Demographics
NPI:1760991624
Name:MCGILLICUDDY, ELIZABETH MICHELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MICHELLE
Last Name:MCGILLICUDDY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ROBERT DANIEL DR APT 5104
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7346
Mailing Address - Country:US
Mailing Address - Phone:254-644-7103
Mailing Address - Fax:
Practice Address - Street 1:4000 MABELINE RD
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410-4651
Practice Address - Country:US
Practice Address - Phone:843-553-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist