Provider Demographics
NPI:1578182101
Name:ROBERTS, SHANNON LEIGH (DC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 ALICE DR APT 301
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2445
Mailing Address - Country:US
Mailing Address - Phone:732-239-9905
Mailing Address - Fax:
Practice Address - Street 1:11 E CALHOUN ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4315
Practice Address - Country:US
Practice Address - Phone:732-581-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC.4549111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor