Basic Information
| Provider Information | |||||||||
| NPI: | 1013193820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESHIELDS BOYKIN | ||||||||
| FirstName: | GENEA | ||||||||
| MiddleName: | DESHIELDS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSP CCC SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DESHIELDS | ||||||||
| OtherFirstName: | GENEA | ||||||||
| OtherMiddleName: | OLISHA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 355 RIDGE RUN TRAIL | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032712364 | ||||||||
| FaxNumber: | 8037085618 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 RIDGE RUN TRAIL | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032712364 | ||||||||
| FaxNumber: | 8037085618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2008 | ||||||||
| LastUpdateDate: | 01/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3951 | SC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.