Provider Demographics
NPI:1326003153
Name:ERICKSON, SHANNON RAE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:RAE
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:2951 MARINA BAY DR STE 130-577
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2735
Mailing Address - Country:US
Mailing Address - Phone:970-335-8115
Mailing Address - Fax:
Practice Address - Street 1:800 MARINERS DR
Practice Address - Street 2:
Practice Address - City:KEMAH
Practice Address - State:TX
Practice Address - Zip Code:77565
Practice Address - Country:US
Practice Address - Phone:970-335-8115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001761235Z00000X
NM4412235Z00000X
TX113334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U956OtherBLUE CROSS
AR142860721Medicaid