Provider Demographics
NPI:1346322112
Name:TUCKER, SHANNON LYNN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E WOODLAWN RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-2202
Mailing Address - Country:US
Mailing Address - Phone:704-523-8027
Mailing Address - Fax:704-523-8031
Practice Address - Street 1:210 E WOODLAWN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-2202
Practice Address - Country:US
Practice Address - Phone:704-523-8027
Practice Address - Fax:704-523-8031
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4977235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411674Medicaid