Provider Demographics
NPI:1407302706
Name:SHENANDOAH SOUNDSTART, LLC
Entity Type:Organization
Organization Name:SHENANDOAH SOUNDSTART, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:540-514-8486
Mailing Address - Street 1:1330 AMHERST ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3000
Mailing Address - Country:US
Mailing Address - Phone:540-514-8486
Mailing Address - Fax:540-301-3618
Practice Address - Street 1:1330 AMHERST ST STE D
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3020
Practice Address - Country:US
Practice Address - Phone:540-514-8486
Practice Address - Fax:540-301-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891976163Medicaid