Provider Demographics
NPI:1053647651
Name:MITCHELL, SHANNEN MARCIE (HIS)
Entity Type:Individual
Prefix:MS
First Name:SHANNEN
Middle Name:MARCIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-335-2597
Practice Address - Street 1:3937 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3202
Practice Address - Country:US
Practice Address - Phone:817-238-9737
Practice Address - Fax:817-238-9963
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80378237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist