Provider Demographics
NPI:1912576661
Name:GRIFFIN, OLIVIA KERTRELL
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KERTRELL
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 LAKE MURRAY BLVD APT 9106
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-0845
Mailing Address - Country:US
Mailing Address - Phone:601-507-9915
Mailing Address - Fax:
Practice Address - Street 1:720 OLD CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9406
Practice Address - Country:US
Practice Address - Phone:803-490-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty