Provider Demographics
NPI:1356439806
Name:KIDD, SHANNON MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:KIDD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 LINK DR
Mailing Address - Street 2:
Mailing Address - City:PINE KNOT
Mailing Address - State:KY
Mailing Address - Zip Code:42635-9155
Mailing Address - Country:US
Mailing Address - Phone:606-310-9795
Mailing Address - Fax:606-354-3537
Practice Address - Street 1:93 LINK DR
Practice Address - Street 2:
Practice Address - City:PINE KNOT
Practice Address - State:KY
Practice Address - Zip Code:42635-9155
Practice Address - Country:US
Practice Address - Phone:606-310-9795
Practice Address - Fax:606-354-3537
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-2595235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist