Provider Demographics
NPI:1225111602
Name:GIBBONS, SHANNON R (MA, FAAA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MA, FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD STE 300N
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5703
Mailing Address - Country:US
Mailing Address - Phone:281-286-2999
Mailing Address - Fax:512-607-4893
Practice Address - Street 1:27 HARTFORD TURNPIKE
Practice Address - Street 2:RT#83
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066
Practice Address - Country:US
Practice Address - Phone:860-646-7900
Practice Address - Fax:860-646-7792
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
237700000X
CT000356237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400031083OtherMEDICARE