Provider Demographics
NPI:1417098039
Name:BERRIAN, SHANNON B (PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:BERRIAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 W MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2500
Practice Address - Country:US
Practice Address - Phone:803-358-6115
Practice Address - Fax:803-358-6117
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3916OtherLICENSE