Provider Demographics
NPI:1972188027
Name:SMITH, SHANNON IRENE
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:IRENE
Last Name:SMITH
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 1:131 MAYLAND CT
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2116
Mailing Address - Country:US
Mailing Address - Phone:803-238-9464
Mailing Address - Fax:
Practice Address - Street 1:1625 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-8626
Practice Address - Country:US
Practice Address - Phone:803-238-9464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10364225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist