Provider Demographics
NPI:1285859264
Name:INTELISANO, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:INTELISANO
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 1:15796 GEORGIA RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-9261
Mailing Address - Country:US
Mailing Address - Phone:440-221-4296
Mailing Address - Fax:
Practice Address - Street 1:15796 GEORGIA RD
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-9261
Practice Address - Country:US
Practice Address - Phone:440-221-4296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP5758235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist