Provider Demographics
NPI:1336792472
Name:PRYOR, ANTOINETTE DOMINIQUE (SLP)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:DOMINIQUE
Last Name:PRYOR
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9325 BLUE HOUSE RD APT 11105
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4230
Mailing Address - Country:US
Mailing Address - Phone:803-873-2243
Mailing Address - Fax:
Practice Address - Street 1:9325 BLUE HOUSE RD APT 11105
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4230
Practice Address - Country:US
Practice Address - Phone:803-873-2243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4382235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist