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NPI Code Detail

MEDICARE: MISS SHANNON DERVAY LPC, NCC, CACI

MEDICARE: MISS SHANNON DERVAY LPC, NCC, CACI
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
1101YA0400XAddiction (Substance Use Disorder) Counselor1105055SC
2101YP2500XProfessional Counselor5145SC
3101YP2500XProfessional Counselor8163NC
4101YP2500XProfessional Counselor56127NC

General Provider Information

NPI Number : 1518254416
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS SHANNON DERVAY LPC, NCC, CACI
Provider Business Mailing Address
First Line : 444 SCARLETT LN
Second Line :
City : FORT MILL
State : SC
Zip : 29715-8213
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 130 HUDSON ST
Second Line :
City : CHESTER
State : SC
Zip : 29706-1524
Country : US
Telephone Number : 803-377-8111
Fax Number : 803-581-5380
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2011
Last Update Date : 06/30/2011

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Directions to “ MISS SHANNON DERVAY LPC, NCC, CACI” Practice Location

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