MEDICARE: INNOVATIVE PEDIATRIC THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	4259	SC

General Provider Information

NPI Number	:	1982833893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PEDIATRIC THERAPY

Provider Business Mailing Address
First Line	:	632 WHITE CHAPEL CIR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-4351
Country	:	US
Telephone Number	:	910-736-1861
Fax Number	:

Provider Business Practice Location Address
First Line	:	632 WHITE CHAPEL CIR
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-4351
Country	:	US
Telephone Number	:	910-736-1861
Fax Number	:

Authorized Official
Title or Position	:	OWNER, SPEECH PATHOLOGIST
Name	:	ELIZABETH JOHNSTON SMITHSON
Credential	:	MSP, CCC SLP
Telephone Number	:	910-736-1861

Provider Enumeration Date	:	07/13/2009
Last Update Date	:	07/13/2009

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Directions to “INNOVATIVE PEDIATRIC THERAPY ” Practice Location

Language	Start Address	Practice Location

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