Provider Demographics
NPI:1467817072
Name:ROBERTS, SHANNON (PTA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 BETHESDA RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-5710
Mailing Address - Country:US
Mailing Address - Phone:864-590-1542
Mailing Address - Fax:
Practice Address - Street 1:175 BURDETTE ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1003
Practice Address - Country:US
Practice Address - Phone:864-596-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-24
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1346174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist