Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 12469 | SC |
NPI | 1003465675 |
---|---|
Provider Name | Shane R Smith |
First Address | Moncks Corner, SC 29461-3967 |
Second Address | Moncks Corner, SC 29461-3967 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2019 |
Last Update Date | 06/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
435201 | (05) | SC |