Healthcare Provider Details

I. General information

NPI: 1861248031
Provider Name (Legal Business Name): SHANEIKA KEYATTA MIXSON CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2024
Last Update Date: 04/27/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 HARD SCRABBLE RD APT 216
COLUMBIA SC
29229-9366
US

IV. Provider business mailing address

4920 HARD SCRABBLE RD APT 216
COLUMBIA SC
29229-9366
US

V. Phone/Fax

Practice location:
  • Phone: 803-346-9019
  • Fax:
Mailing address:
  • Phone: 803-346-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8140
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: