Provider Demographics
NPI:1740810183
Name:HAYNES, SHANNON JEAN (LISW-CP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:JEAN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:PIERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:136-4 FORUM DRIVE
Mailing Address - Street 2:169
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7089
Mailing Address - Country:US
Mailing Address - Phone:803-220-4288
Mailing Address - Fax:
Practice Address - Street 1:136-4 FORUM DRIVE
Practice Address - Street 2:169
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7089
Practice Address - Country:US
Practice Address - Phone:803-220-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC134391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1740810183Medicaid