Provider Demographics
NPI:1063864296
Name:LEATHERS, TORI
Entity type:Individual
Prefix:
First Name:TORI
Middle Name:
Last Name:LEATHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1634 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3451
Mailing Address - Country:US
Mailing Address - Phone:803-410-5483
Mailing Address - Fax:
Practice Address - Street 1:1634 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3451
Practice Address - Country:US
Practice Address - Phone:803-410-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6027235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1674Medicaid