Healthcare Provider Details

I. General information

NPI: 1184870206
Provider Name (Legal Business Name): PALMETTO SPEECH & LANGUAGE ASSOC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3185 AZALEA DRIVE
NORTH CHARLESTON SC
29405
US

IV. Provider business mailing address

1150 HUNGRYNECK BLVD SUITE C-364
MOUNT PLEASANT SC
29464
US

V. Phone/Fax

Practice location:
  • Phone: 843-388-9990
  • Fax: 843-388-0349
Mailing address:
  • Phone: 843-388-9990
  • Fax: 843-388-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3120
License Number StateSC

VIII. Authorized Official

Name: MS. GENA C RANDOLPH
Title or Position: OWNER
Credential: MA, CCC-SLP
Phone: 843-388-9990