Provider Demographics
NPI:1770531063
Name:SHANK, JOSEPH NORMAN (LISW-CP/S, LMFT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:NORMAN
Last Name:SHANK
Suffix:
Gender:M
Credentials:LISW-CP/S, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OUTLET POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5667
Mailing Address - Country:US
Mailing Address - Phone:803-722-6540
Mailing Address - Fax:803-772-6542
Practice Address - Street 1:200 OUTLET POINTE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5667
Practice Address - Country:US
Practice Address - Phone:803-722-6540
Practice Address - Fax:803-772-6542
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6881041C0700X
SC58106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ291419190Medicare PIN