Provider Demographics
NPI:1508933383
Name:FORMAN, SHANNON (4188)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:4188
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BLASSINGAME RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-3304
Mailing Address - Country:US
Mailing Address - Phone:864-355-3100
Mailing Address - Fax:864-355-9828
Practice Address - Street 1:100 BLASSINGAME RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-3304
Practice Address - Country:US
Practice Address - Phone:864-355-3100
Practice Address - Fax:864-355-9828
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3471235Z00000X
SC4188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884220500Medicaid