Healthcare Provider Details

I. General information

NPI: 1891665451
Provider Name (Legal Business Name): SHANAUTICA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 FLORIDA AVE APT 81
GREENWOOD SC
29646-4446
US

IV. Provider business mailing address

235 FLORIDA AVE APT 81
GREENWOOD SC
29646-4446
US

V. Phone/Fax

Practice location:
  • Phone: 864-396-6352
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: