=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750788410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHERN TIDES SPEECH AND LANGUAGE L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2014
-----------------------------------------------------
Last Update Date | 02/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1744 SAM RITTENBERG BLVD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-4935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-423-6613
-----------------------------------------------------
Fax | 843-375-6177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1329 NATIONAL DR
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29466-8979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-708-9138
-----------------------------------------------------
Fax | 843-375-6177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH AND LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MR. STEPHEN A CUTIA
-----------------------------------------------------
Credential | M.S. CCC-SLP
-----------------------------------------------------
Telephone | 607-423-6613
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 4986
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------