Provider Demographics
NPI:1922732759
Name:LAKE MURRAY SPEECH PATHOLOGY LLC
Entity Type:Organization
Organization Name:LAKE MURRAY SPEECH PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUIDENIER
Authorized Official - Suffix:
Authorized Official - Credentials:MCD, CCC-SLP
Authorized Official - Phone:803-586-1447
Mailing Address - Street 1:111 HAYWAIN DR
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8204
Mailing Address - Country:US
Mailing Address - Phone:803-586-1447
Mailing Address - Fax:
Practice Address - Street 1:111 HAYWAIN DR
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8204
Practice Address - Country:US
Practice Address - Phone:803-586-1447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty