Provider Demographics
NPI:1235275157
Name:FOTINOS, MARJORIE L (SLP)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:L
Last Name:FOTINOS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:
Other - Last Name:LOCKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 ENTERPRISE BLVD
Mailing Address - Street 2:STE. 250
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6300
Mailing Address - Country:US
Mailing Address - Phone:864-454-0888
Mailing Address - Fax:864-454-1130
Practice Address - Street 1:29 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2629
Practice Address - Country:US
Practice Address - Phone:864-331-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0560Medicaid