Healthcare Provider Details

I. General information

NPI: 1033675061
Provider Name (Legal Business Name): WEST ASHLEY PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2738 BOLINAS CT
CHARLESTON SC
29414-6686
US

IV. Provider business mailing address

2738 BOLINAS CT
CHARLESTON SC
29414-6686
US

V. Phone/Fax

Practice location:
  • Phone: 302-359-3468
  • Fax:
Mailing address:
  • Phone: 302-359-3468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MEGAN DEARING
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 302-359-3468