Provider Demographics
NPI:1033426812
Name:BALFOUR, SHANELLE NATALIE (P T)
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:NATALIE
Last Name:BALFOUR
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 LOWER CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:NEESES
Mailing Address - State:SC
Mailing Address - Zip Code:29107-9546
Mailing Address - Country:US
Mailing Address - Phone:904-392-1150
Mailing Address - Fax:
Practice Address - Street 1:1620 BROUGHTON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4867
Practice Address - Country:US
Practice Address - Phone:803-534-4050
Practice Address - Fax:803-534-0408
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6055225100000X
SC3598225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist