MEDICARE: MRS. SHANTA AVALICE JERIDEAU LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1316290901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANTA AVALICE JERIDEAU LPC

Provider Business Mailing Address
First Line	:	200 SPRINGTREE DR STE 200
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-8614
Country	:	US
Telephone Number	:	803-722-4975
Fax Number	:	803-722-6018

Provider Business Practice Location Address
First Line	:	200 SPRINGTREE DR STE 200
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-8614
Country	:	US
Telephone Number	:	803-722-4975
Fax Number	:	803-722-6018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	11/03/2020

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