Provider Demographics
NPI:1326409335
Name:SHAW, COURTNEY NICOLE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:NICOLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:COURTNEY
Other - Middle Name:NICOLE
Other - Last Name:PUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:316 ROCKY HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339
Mailing Address - Country:US
Mailing Address - Phone:662-803-5250
Mailing Address - Fax:
Practice Address - Street 1:316 ROCKY HILL ROAD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339
Practice Address - Country:US
Practice Address - Phone:662-803-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist