Healthcare Provider Details

I. General information

NPI: 1760387013
Provider Name (Legal Business Name): ERICA SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W HAMPTON AVE
SUMTER SC
29150-4912
US

IV. Provider business mailing address

9 N PIKE W
SUMTER SC
29153-2025
US

V. Phone/Fax

Practice location:
  • Phone: 803-795-1003
  • Fax:
Mailing address:
  • Phone: 803-795-1003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number269067
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: