Provider Demographics
NPI:1134747694
Name:ROUSE, TEDRO RAMONE (CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:TEDRO
Middle Name:RAMONE
Last Name:ROUSE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:DR
Other - First Name:T.
Other - Middle Name:RAMONE
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2828 LAKESIDE ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-1818
Mailing Address - Country:US
Mailing Address - Phone:803-997-0154
Mailing Address - Fax:
Practice Address - Street 1:2828 LAKESIDE ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1818
Practice Address - Country:US
Practice Address - Phone:803-997-0154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3578235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist