Provider Demographics
NPI:1407426729
Name:SHANNON, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:SHANNON
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 1:400 BELCHASE DR STE 406
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-9760
Mailing Address - Country:US
Mailing Address - Phone:732-851-6947
Mailing Address - Fax:
Practice Address - Street 1:400 BELCHASE DR STE 406
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-9760
Practice Address - Country:US
Practice Address - Phone:732-851-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14413934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ471300603OtherSPEECH-LANGUAGE PATHOLOGY