Provider Demographics
NPI:1992869515
Name:MATTHEWS, CONNIE SMITH (AU,D)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:SMITH
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:AU,D
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:SMITH
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1721 EBENEZER RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-4103
Mailing Address - Country:US
Mailing Address - Phone:803-329-1520
Mailing Address - Fax:803-366-5027
Practice Address - Street 1:1721 EBENEZER RD
Practice Address - Street 2:SUITE 225
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-4103
Practice Address - Country:US
Practice Address - Phone:803-329-1520
Practice Address - Fax:803-366-5027
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2245231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC355738Medicaid