Provider Demographics
NPI:1336475318
Name:PENDERGRASS, SHAUNA BRIAWN (MRC)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:BRIAWN
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:MRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 COLONIAL DR
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:803-898-1555
Mailing Address - Fax:
Practice Address - Street 1:2715 COLONIAL DR
Practice Address - Street 2:SUITE 200A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-898-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322842Medicaid
SC3347Medicare PIN