Healthcare Provider Details

I. General information

NPI: 1013133958
Provider Name (Legal Business Name): ANNIE SAMANTHA BONNETTE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 JADE CIR
ORANGEBURG SC
29115-8166
US

IV. Provider business mailing address

320 CULLER ST
ORANGEBURG SC
29115-5315
US

V. Phone/Fax

Practice location:
  • Phone: 803-533-8092
  • Fax:
Mailing address:
  • Phone: 803-707-8788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3880
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: