Provider Demographics
NPI:1053832329
Name:MCCORMICK, SHANNON LEIGH (AUD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEIGH
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 BLUE MARLIN DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-8487
Mailing Address - Country:US
Mailing Address - Phone:941-773-0566
Mailing Address - Fax:
Practice Address - Street 1:2180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1625
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAUD-175231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist