Healthcare Provider Details

I. General information

NPI: 1003274481
Provider Name (Legal Business Name): KRYSTINA MANTZOURANIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 08/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 LEEDS AVE
NORTH CHARLESTON SC
29405-6861
US

IV. Provider business mailing address

1575 NANTAHALA BLVD
MOUNT PLEASANT SC
29464-9753
US

V. Phone/Fax

Practice location:
  • Phone: 843-529-3130
  • Fax:
Mailing address:
  • Phone: 757-642-1452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: