MEDICARE: DR. SHAWNA BLAKE KIRBY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1251	SC
2	103G00000X	Clinical Neuropsychologist	1251	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174686356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAWNA BLAKE KIRBY PHD

Provider Business Mailing Address
First Line	:	1505 CHARLESTON HWY
Second Line	:	# 1523
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-5069
Country	:	US
Telephone Number	:	803-995-1838
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 CHARLESTON HWY
Second Line	:	# 1523
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-5069
Country	:	US
Telephone Number	:	803-497-3640
Fax Number	:	888-352-7678

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	02/28/2024

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