Provider Demographics
NPI:1740504851
Name:POWERS, THERESA J (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:J
Last Name:POWERS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:J
Other - Last Name:WALLAART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1407 ASHLEY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5305
Mailing Address - Country:US
Mailing Address - Phone:843-769-0663
Mailing Address - Fax:843-769-0665
Practice Address - Street 1:1407 ASHLEY RIVER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5305
Practice Address - Country:US
Practice Address - Phone:843-769-0663
Practice Address - Fax:843-769-0665
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4133235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4133OtherSPEECH-LANGUAGE LICENSE NUMBER