=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194075457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIELLE ROSE NEWBERRY MSP CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2012
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 VISTA SPRINGS CIR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29072-8119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-359-3195
-----------------------------------------------------
Fax | 803-359-3195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3185 JOHN BARTRAM PL
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29466-7025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-654-9500
-----------------------------------------------------
Fax | 803-359-3195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 5084
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------