Healthcare Provider Details

I. General information

NPI: 1326599200
Provider Name (Legal Business Name): SHANNON PARADISE LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 ADLEY WAY
GREENVILLE SC
29607-6511
US

IV. Provider business mailing address

225 ADLEY WAY
GREENVILLE SC
29607-6511
US

V. Phone/Fax

Practice location:
  • Phone: 864-987-9747
  • Fax: 864-987-9770
Mailing address:
  • Phone: 864-987-9747
  • Fax: 864-987-9770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8984
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: