MEDICARE: PEDIATRIC SPEECH THERAPY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	3360	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265665335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC SPEECH THERAPY SERVICES

Provider Business Mailing Address
First Line	:	820 KIPLING DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29205-2036
Country	:	US
Telephone Number	:	803-315-5252
Fax Number	:	803-787-2973

Provider Business Practice Location Address
First Line	:	820 KIPLING DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29205-2036
Country	:	US
Telephone Number	:	803-315-5252
Fax Number	:	803-787-2973

Authorized Official
Title or Position	:	SPEECH-LANGUAGE PATHOLOGIST
Name	:	MRS. MARYMAC WILLIAMS
Credential	:	MA, CCC/SLP
Telephone Number	:	803-315-5252

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	08/24/2009

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