Basic Information
| Provider Information | |||||||||
| NPI: | 1245554104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOWCOUNTRY THERAPY CENTER, LLC | ||||||||
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| OtherOrganizationName: | LOWCOUNTRY THERAPY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2421 | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439702899 | ||||||||
| FaxNumber: | 8438156998 | ||||||||
| Practice Location | |||||||||
| Address1: | 254 RED CEDAR STREET, SUITE 9 | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299108967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439702899 | ||||||||
| FaxNumber: | 8438156998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | FUSTOS | ||||||||
| AuthorizedOfficialFirstName: | JESSI | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7327625572 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MA, CCC-SLP | ||||||||
| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | 4245 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.