Provider Demographics
NPI:1407125479
Name:DIALS-CORUJO, SHANEEN (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:SHANEEN
Middle Name:
Last Name:DIALS-CORUJO
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MRS
Other - First Name:SHANEEN
Other - Middle Name:
Other - Last Name:CORUJO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:PO BOX 2942
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-8042
Mailing Address - Country:US
Mailing Address - Phone:803-378-2910
Mailing Address - Fax:
Practice Address - Street 1:141 RED BANK ROAD
Practice Address - Street 2:STE D
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-8042
Practice Address - Country:US
Practice Address - Phone:803-378-2910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5281101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional