Provider Demographics
NPI:1700131414
Name:HICKS, SHANNON MILLER (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MILLER
Last Name:HICKS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2918
Mailing Address - Country:US
Mailing Address - Phone:803-779-8327
Mailing Address - Fax:803-799-3603
Practice Address - Street 1:6041 GARNERS FERRY RD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1304
Practice Address - Country:US
Practice Address - Phone:803-783-0684
Practice Address - Fax:803-783-1147
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42-6542OtherMEDICARE FACILITY PROVIDER NUMBER
SC6742OtherSC BOARD OF PHYSICAL THERAPY EXAMINERS