Provider Demographics
NPI:1538727417
Name:EARTHSHINE SPEECH AND LANGUAGE
Entity type:Organization
Organization Name:EARTHSHINE SPEECH AND LANGUAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AFHTON
Authorized Official - Middle Name:P
Authorized Official - Last Name:STETZER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:770-841-0564
Mailing Address - Street 1:734 BENNETT ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-5723
Mailing Address - Country:US
Mailing Address - Phone:770-841-0564
Mailing Address - Fax:
Practice Address - Street 1:1 CHICK SPRINGS RD STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4953
Practice Address - Country:US
Practice Address - Phone:770-841-0564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA1676Medicaid