=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902337652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA RIEDY MA, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2017
-----------------------------------------------------
Last Update Date | 03/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 OLD FORT DR
-----------------------------------------------------
City | LADSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29456-5279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-821-1165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 OLD FORT DR
-----------------------------------------------------
City | LADSON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29456-5279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-821-1165
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------