Provider Demographics
NPI:1003308693
Name:KALLSEN, SHANNON AMBER (MS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:AMBER
Last Name:KALLSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 TRAVIS ST APT C
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4117
Mailing Address - Country:US
Mailing Address - Phone:505-385-5571
Mailing Address - Fax:
Practice Address - Street 1:15820 ADDISON RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3549
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114495235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist