1013193820 NPI number — MRS. GENEA DESHIELDS DESHIELDS BOYKIN MSP CCC SLP

Table of content: MRS. GENEA DESHIELDS DESHIELDS BOYKIN MSP CCC SLP (NPI 1013193820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013193820 NPI number — MRS. GENEA DESHIELDS DESHIELDS BOYKIN MSP CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESHIELDS BOYKIN
Provider First Name:
GENEA
Provider Middle Name:
DESHIELDS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSP CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DESHIELDS
Provider Other First Name:
GENEA
Provider Other Middle Name:
OLISHA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013193820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355 RIDGE RUN TRAIL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRMO
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-271-2364
Provider Business Mailing Address Fax Number:
803-708-5618

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 RIDGE RUN TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRMO
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-271-2364
Provider Business Practice Location Address Fax Number:
803-708-5618
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  3951 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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