Provider Demographics
NPI:1851402432
Name:SHAW, SHANITA D (MA CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:SHANITA
Middle Name:D
Last Name:SHAW
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-4003
Mailing Address - Country:US
Mailing Address - Phone:803-378-5284
Mailing Address - Fax:803-531-6322
Practice Address - Street 1:2495 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-4003
Practice Address - Country:US
Practice Address - Phone:803-378-5284
Practice Address - Fax:803-531-6322
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0712Medicaid