Provider Demographics
NPI:1982833893
Name:INNOVATIVE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:INNOVATIVE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JOHNSTON
Authorized Official - Last Name:SMITHSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSP, CCC SLP
Authorized Official - Phone:910-736-1861
Mailing Address - Street 1:632 WHITE CHAPEL CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4351
Mailing Address - Country:US
Mailing Address - Phone:910-736-1861
Mailing Address - Fax:
Practice Address - Street 1:632 WHITE CHAPEL CIR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-4351
Practice Address - Country:US
Practice Address - Phone:910-736-1861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty