Provider Demographics
NPI:1083796601
Name:KONG, SHANNON L (MS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:KONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LODGEPOLE CT
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3461
Mailing Address - Country:US
Mailing Address - Phone:925-708-9020
Mailing Address - Fax:888-429-1415
Practice Address - Street 1:100 LONGBROOK WAY STE 2
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-7775
Practice Address - Country:US
Practice Address - Phone:510-250-9199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP10617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist