Healthcare Provider Details

I. General information

NPI: 1659291185
Provider Name (Legal Business Name): MRS. SHANNON MARIE CYR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 MAIN ST # 230
NORTH MYRTLE BEACH SC
29582-3030
US

IV. Provider business mailing address

826 DRAGONFLY WAY
CONWAY SC
29526-0006
US

V. Phone/Fax

Practice location:
  • Phone: 813-763-5469
  • Fax: 813-441-8362
Mailing address:
  • Phone: 978-317-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number0108085889
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: