Provider Demographics
NPI:1821721606
Name:VAN HULLE, MARY CLARE (SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CLARE
Last Name:VAN HULLE
Suffix:
Gender:
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9565 HIGHWAY 78 STE 102
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4118
Mailing Address - Country:US
Mailing Address - Phone:843-569-4546
Mailing Address - Fax:843-569-4535
Practice Address - Street 1:9565 HIGHWAY 78 STE 102
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4118
Practice Address - Country:US
Practice Address - Phone:843-569-4546
Practice Address - Fax:843-569-4535
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC16398015OtherCAQH
SC9090OtherSTATE LICENSE
SCSA3027Medicaid