Healthcare Provider Details

I. General information

NPI: 1780790519
Provider Name (Legal Business Name): NICHOLE MONTGOMERY HUNT MSP,CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 TRIDENT MAPLE CT
FOUNTAIN INN SC
29644-2132
US

IV. Provider business mailing address

103 TRIDENT MAPLE CT
FOUNTAIN INN SC
29644-2132
US

V. Phone/Fax

Practice location:
  • Phone: 864-409-8671
  • Fax:
Mailing address:
  • Phone: 864-409-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2767
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: