Healthcare Provider Details

I. General information

NPI: 1689045429
Provider Name (Legal Business Name): SHANNON WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 BAYVIEW ST
HOLLY HILL SC
29059-8583
US

IV. Provider business mailing address

1061 BAYVIEW ST
HOLLY HILL SC
29059-8583
US

V. Phone/Fax

Practice location:
  • Phone: 803-971-0689
  • Fax:
Mailing address:
  • Phone: 803-971-0689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: