Provider Demographics
NPI:1689045429
Name:WATSON, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WATSON
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 1:1061 BAYVIEW ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29059-8583
Mailing Address - Country:US
Mailing Address - Phone:803-971-0689
Mailing Address - Fax:
Practice Address - Street 1:1061 BAYVIEW ST
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-8583
Practice Address - Country:US
Practice Address - Phone:803-971-0689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service