Provider Demographics
NPI:1154679850
Name:SARGENT, SHAUNA FREDRICKS
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:FREDRICKS
Last Name:SARGENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3503
Mailing Address - Country:US
Mailing Address - Phone:321-536-1845
Mailing Address - Fax:
Practice Address - Street 1:516 BARNES ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80930-7017
Practice Address - Country:US
Practice Address - Phone:719-359-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11464235Z00000X
COMSSLP.0000002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist