Provider Demographics
NPI:1184870206
Name:PALMETTO SPEECH & LANGUAGE ASSOC, LLC
Entity type:Organization
Organization Name:PALMETTO SPEECH & LANGUAGE ASSOC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GENA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:843-388-9990
Mailing Address - Street 1:1150 HUNGRYNECK BLVD
Mailing Address - Street 2:SUITE C-364
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-388-9990
Mailing Address - Fax:843-388-0349
Practice Address - Street 1:3185 AZALEA DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405
Practice Address - Country:US
Practice Address - Phone:843-388-9990
Practice Address - Fax:843-388-0349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty