Healthcare Provider Details

I. General information

NPI: 1689321978
Provider Name (Legal Business Name): SHANON DEAN LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 12/16/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2029 W DEKALB ST
CAMDEN SC
29020-2093
US

IV. Provider business mailing address

2029 W DEKALB ST
CAMDEN SC
29020-2093
US

V. Phone/Fax

Practice location:
  • Phone: 803-432-8416
  • Fax:
Mailing address:
  • Phone: 803-432-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number14561
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17113
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: