Provider Demographics
NPI:1124225412
Name:WATTERS, SHANNON MICHELLE (M,A, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:WATTERS
Suffix:
Gender:F
Credentials:M,A, CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:POE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5831 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5303
Mailing Address - Country:US
Mailing Address - Phone:817-233-5526
Mailing Address - Fax:
Practice Address - Street 1:520 NW WALL ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2608
Practice Address - Country:US
Practice Address - Phone:541-355-6949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR013099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist