Provider Demographics
NPI:1588822704
Name:AIKEN, SHANNON NICOLE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:AIKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 PROFESSIONAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7626
Mailing Address - Country:US
Mailing Address - Phone:864-938-0912
Mailing Address - Fax:864-938-0926
Practice Address - Street 1:442 PROFESSIONAL PARK RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7626
Practice Address - Country:US
Practice Address - Phone:864-938-0912
Practice Address - Fax:864-938-0926
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC3333Medicare PIN