Provider Demographics
NPI:1053683995
Name:UTLEY, SHANNEN DOROTHEA (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNEN
Middle Name:DOROTHEA
Last Name:UTLEY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 JONES RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4855
Mailing Address - Country:US
Mailing Address - Phone:832-663-7541
Mailing Address - Fax:832-717-2808
Practice Address - Street 1:12345 JONES RD
Practice Address - Street 2:SUITE 215
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4855
Practice Address - Country:US
Practice Address - Phone:832-663-7541
Practice Address - Fax:832-717-2808
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102409235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist