Healthcare Provider Details

I. General information

NPI: 1629734124
Provider Name (Legal Business Name): MP SPEECH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 SCOTT WAY
BLUFFTON SC
29910-8714
US

IV. Provider business mailing address

52 9TH AVE
BLUFFTON SC
29910-7670
US

V. Phone/Fax

Practice location:
  • Phone: 843-259-2759
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MADISON PRUITT
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.A. CCC-SLP
Phone: 302-584-4740