Provider Demographics
NPI:1942590088
Name:COSTNER, MALLORIE BRYAN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORIE
Middle Name:BRYAN
Last Name:COSTNER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 HUNTINGTON ROAD
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642
Mailing Address - Country:US
Mailing Address - Phone:864-918-2361
Mailing Address - Fax:
Practice Address - Street 1:507 HUNTINGTON ROAD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642
Practice Address - Country:US
Practice Address - Phone:864-918-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5677235Z00000X
IDSLP - 2084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist