Provider Demographics
NPI:1841048204
Name:GILLENS, SHAWN (M A CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:GILLENS
Suffix:
Gender:M
Credentials:M A CCC-SLP
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 21246
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29221-1246
Mailing Address - Country:US
Mailing Address - Phone:803-546-6227
Mailing Address - Fax:
Practice Address - Street 1:1401 FARRINGTON WAY APT B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-6076
Practice Address - Country:US
Practice Address - Phone:803-546-6227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist