Provider Demographics
NPI:1205215407
Name:BOTHWELL, SHANNON ELYSE (MS SLP-CFY)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELYSE
Last Name:BOTHWELL
Suffix:
Gender:F
Credentials:MS SLP-CFY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11236 N US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:ODON
Mailing Address - State:IN
Mailing Address - Zip Code:47562-5602
Mailing Address - Country:US
Mailing Address - Phone:812-486-8596
Mailing Address - Fax:
Practice Address - Street 1:6239 S EAST ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2088
Practice Address - Country:US
Practice Address - Phone:317-442-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002739A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist