Provider Demographics
NPI:1639187487
Name:BASONG, SHERMAN KEVIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHERMAN
Middle Name:KEVIN
Last Name:BASONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ROPER MOUNTAIN ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4886
Mailing Address - Country:US
Mailing Address - Phone:864-242-1163
Mailing Address - Fax:864-242-1167
Practice Address - Street 1:10 ENTERPRISE BLVD
Practice Address - Street 2:STE 201
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3554
Practice Address - Country:US
Practice Address - Phone:864-583-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPTLICENSE2637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1959Medicaid