=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790109650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA SPEECH PATHOLOGY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2014
-----------------------------------------------------
Last Update Date | 02/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 E WASHINGTON ST UNIT C
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-3982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-419-7576
-----------------------------------------------------
Fax | 843-552-5122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 CEDAR GROVE DR
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29420-8146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-419-7576
-----------------------------------------------------
Fax | 843-552-5122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LISA BAXTER
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 843-419-7576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | 969
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------