Provider Demographics
NPI:1346682911
Name:STACK, SHANNA LEE
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEE
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:LEE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CF-SLP
Mailing Address - Street 1:3031 S RUSSELL ST STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8523
Mailing Address - Country:US
Mailing Address - Phone:406-396-4130
Mailing Address - Fax:406-797-5008
Practice Address - Street 1:3031 S RUSSELL ST STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8523
Practice Address - Country:US
Practice Address - Phone:406-396-4130
Practice Address - Fax:406-797-5008
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-TMP-3159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist