Provider Demographics
NPI:1194181073
Name:HAGGERTY, SHANNON
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:
Last Name:HAGGERTY
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 1:91 PERIMETER RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13441-4018
Mailing Address - Country:US
Mailing Address - Phone:315-336-8302
Mailing Address - Fax:315-339-0958
Practice Address - Street 1:91 PERIMETER RD
Practice Address - Street 2:SUITE 180
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441-4018
Practice Address - Country:US
Practice Address - Phone:315-336-8302
Practice Address - Fax:315-339-0958
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000045365237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist