Provider Demographics
NPI:1053074195
Name:KRUGOLETS, SHANNA MICHELLE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:MICHELLE
Last Name:KRUGOLETS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057-1205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2806 GEORGE ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NY
Practice Address - Zip Code:14057-1205
Practice Address - Country:US
Practice Address - Phone:716-366-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist