Provider Demographics
NPI:1700947751
Name:DOUGHTY, SHANNON S (PHD, BCBA)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:S
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:PHD, BCBA
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 80901
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-0901
Mailing Address - Country:US
Mailing Address - Phone:843-259-8853
Mailing Address - Fax:
Practice Address - Street 1:1902 OLD PARSONAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-6205
Practice Address - Country:US
Practice Address - Phone:843-259-8853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP8971Medicaid