Provider Demographics
NPI:1073244224
Name:THAYER, SHANNON (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THAYER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 VANDERBILT LOOP
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-2047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3115 HORSEBLOCK RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2526
Practice Address - Country:US
Practice Address - Phone:631-730-3039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030715235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist