Provider Demographics
NPI:1356630016
Name:HUCKABY, SHANNON (MS)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:HUCKABY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LIBBY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1925
Mailing Address - Country:US
Mailing Address - Phone:207-899-3170
Mailing Address - Fax:
Practice Address - Street 1:30 LIBBY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1925
Practice Address - Country:US
Practice Address - Phone:207-899-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME235Z00000X2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant