Healthcare Provider Details

I. General information

NPI: 1437065836
Provider Name (Legal Business Name): ELISE CANUPP BYNUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 CLAYBROOK ST
JOHNS ISLAND SC
29455-7775
US

IV. Provider business mailing address

721 WAPPOO RD
CHARLESTON SC
29407-5861
US

V. Phone/Fax

Practice location:
  • Phone: 843-543-6855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9374
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: