Provider Demographics
NPI:1336264225
Name:PROVEAUX, KRISTY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:PROVEAUX
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4129 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-1264
Mailing Address - Country:US
Mailing Address - Phone:803-600-6519
Mailing Address - Fax:
Practice Address - Street 1:3681 LEAPHART RD STE A
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3068
Practice Address - Country:US
Practice Address - Phone:803-600-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist