Healthcare Provider Details

I. General information

NPI: 1689321978
Provider Name (Legal Business Name): SHANON DEAN LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 POLIFKA DR BLDG 1042
SHAW AFB SC
29152-5100
US

IV. Provider business mailing address

2029 W DEKALB ST
CAMDEN SC
29020-2093
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-6356
  • Fax:
Mailing address:
  • Phone: 803-432-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17113
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number14561
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: