Provider Demographics
NPI:1174686356
Name:KIRBY, SHAWNA BLAKE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHAWNA
Middle Name:BLAKE
Last Name:KIRBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 CHARLESTON HWY
Mailing Address - Street 2:# 1523
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5069
Mailing Address - Country:US
Mailing Address - Phone:803-995-1838
Mailing Address - Fax:
Practice Address - Street 1:1505 CHARLESTON HWY
Practice Address - Street 2:# 1523
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5069
Practice Address - Country:US
Practice Address - Phone:803-497-3640
Practice Address - Fax:888-352-7678
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1251103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0613Medicaid