=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578881512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA DAWES QUATTLEBAUM M.S.P., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2010
-----------------------------------------------------
Last Update Date | 05/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3612 LANDMARK DR STE B
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29204-4039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-315-8705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3612 LANDMARK DR STE B
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29204-4039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-315-8705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 278
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------