Provider Demographics
NPI:1275121006
Name:SHAUGHNESSY, KELLY ANN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 14TH PL S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2107
Mailing Address - Country:US
Mailing Address - Phone:503-409-4754
Mailing Address - Fax:
Practice Address - Street 1:3031 W MARCH LN # 17
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6500
Practice Address - Country:US
Practice Address - Phone:209-952-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR013223235Z00000X
CASP31566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty