Provider Demographics
NPI:1376121699
Name:COYLE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:COYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 HAIRE RD
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-8807
Mailing Address - Country:US
Mailing Address - Phone:803-548-9113
Mailing Address - Fax:
Practice Address - Street 1:1988 HAIRE RD
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8807
Practice Address - Country:US
Practice Address - Phone:803-548-9113
Practice Address - Fax:803-548-9116
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6115225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist