Provider Demographics
NPI:1972014082
Name:MAGOTO, ALEXIS RENEE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:RENEE
Last Name:MAGOTO
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 1:117 BREAKERS DR UNIT 223
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4428
Mailing Address - Country:US
Mailing Address - Phone:937-638-9550
Mailing Address - Fax:
Practice Address - Street 1:101 BRIGHTWATER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-8275
Practice Address - Country:US
Practice Address - Phone:843-236-3579
Practice Address - Fax:843-236-4131
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6381235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist