=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053735936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMETTO SPEECH AND LANGUAGE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2014
-----------------------------------------------------
Last Update Date | 02/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10616 S JACOB SMART BLVD SUITE 103
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29936-8477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-645-8255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10616 S JACOB SMART BLVD SUITE 103
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29936-8477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-645-8255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | KELLY BARRELL
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 843-645-8255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 4726
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------