1215393871 NPI number — MRS. SHANNON LEIGH TYNER THOMPSON BCBA

Table of content: MRS. SHANNON LEIGH TYNER THOMPSON BCBA (NPI 1215393871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215393871 NPI number — MRS. SHANNON LEIGH TYNER THOMPSON BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
SHANNON
Provider Middle Name:
LEIGH TYNER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TYNER
Provider Other First Name:
SHANNON
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215393871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
751 E. GEORGIA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODRUFF
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-476-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 E. GEORGIA STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODRUFF
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-476-7400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-15-21211 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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