Provider Demographics
NPI:1154460038
Name:HICKS, SHANNON (SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10121 COMANCHE RD NE
Mailing Address - Street 2:MITCHELL ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3614
Mailing Address - Country:US
Mailing Address - Phone:505-299-1937
Mailing Address - Fax:
Practice Address - Street 1:10121 COMANCHE RD NE
Practice Address - Street 2:MITCHELL ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3614
Practice Address - Country:US
Practice Address - Phone:505-299-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM433235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ 5479Medicaid