Provider Demographics
NPI:1033403803
Name:LUND, SHANNA JANE (MS/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:JANE
Last Name:LUND
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48720 AVENIDA FERNANDO
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2235
Mailing Address - Country:US
Mailing Address - Phone:760-989-1941
Mailing Address - Fax:
Practice Address - Street 1:78030 CALLE BARCELONA
Practice Address - Street 2:SUITE F
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2996
Practice Address - Country:US
Practice Address - Phone:760-989-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP2034235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP 2034OtherSPEECH PATHOLOGY LICENSE