Provider Demographics
NPI:1396223947
Name:MCNELLIS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCNELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 VERONA CT
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1917
Mailing Address - Country:US
Mailing Address - Phone:410-530-2609
Mailing Address - Fax:
Practice Address - Street 1:5009 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-5353
Practice Address - Country:US
Practice Address - Phone:410-325-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14279776OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION