Provider Demographics
NPI:1700473691
Name:BROWN, SHANITA L
Entity Type:Individual
Prefix:MS
First Name:SHANITA
Middle Name:L
Last Name:BROWN
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:PO BOX 1265
Mailing Address - Street 2:ATTN: POPUP WELLNESS STUDIO L.L.C
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202
Mailing Address - Country:US
Mailing Address - Phone:803-200-2103
Mailing Address - Fax:
Practice Address - Street 1:3906 MARSTELLER STREET
Practice Address - Street 2:ATTN: THE 'M' WORD MASSAGE CLINIC LLC
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-200-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-25
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS.5193225700000X
N6C2N6L2246Y00000X
247000000X
SC124189376K00000X
525885-06225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health InformationGroup - Single Specialty
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty