Provider Demographics
NPI:1780447409
Name:MARTIN, SHANNA (LPC-A)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 RODERICK LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605
Mailing Address - Country:US
Mailing Address - Phone:864-497-5096
Mailing Address - Fax:
Practice Address - Street 1:6715 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1831
Practice Address - Country:US
Practice Address - Phone:864-536-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8839101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional