Provider Demographics
NPI:1508064155
Name:BRIDGES, SHANNON (MSR, SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:MSR, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 ANDERSON RD STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-7651
Mailing Address - Country:US
Mailing Address - Phone:864-295-9890
Mailing Address - Fax:864-295-9894
Practice Address - Street 1:3400 ANDERSON RD STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7651
Practice Address - Country:US
Practice Address - Phone:864-295-9890
Practice Address - Fax:864-295-9894
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4148235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0881Medicaid