Provider Demographics
NPI:1891906798
Name:NICOLE G BENNETT, LLC
Entity Type:Organization
Organization Name:NICOLE G BENNETT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MCD, CCC-SLP
Authorized Official - Phone:803-686-0377
Mailing Address - Street 1:500 BARRY AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924
Mailing Address - Country:US
Mailing Address - Phone:803-686-0377
Mailing Address - Fax:803-943-0706
Practice Address - Street 1:500 BARRY AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-3810
Practice Address - Country:US
Practice Address - Phone:803-686-0377
Practice Address - Fax:803-943-0706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3833Medicaid