Provider Demographics
NPI:1073122313
Name:SPEAKS, SHANNON RAE (LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAE
Last Name:SPEAKS
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6933 SAINT REGIS BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-3224
Mailing Address - Country:US
Mailing Address - Phone:330-554-1196
Mailing Address - Fax:
Practice Address - Street 1:6933 SAINT REGIS BLVD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-3224
Practice Address - Country:US
Practice Address - Phone:330-554-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0900288-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI.0900288-SUPVOtherOHIO COUNSELOR, SOCIAL WORKER & MARRIAGE AND FAMILY THERAPIST BOARD