Provider Demographics
NPI:1376662064
Name:SERVANCE, SHANNON LEWIS (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEWIS
Last Name:SERVANCE
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 1:3154 BONNEY BRIAR DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3113
Mailing Address - Country:US
Mailing Address - Phone:281-438-9973
Mailing Address - Fax:
Practice Address - Street 1:3154 BONNEY BRIAR DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-3113
Practice Address - Country:US
Practice Address - Phone:281-438-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist