Provider Demographics
NPI:1417349267
Name:BRAGG, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRAGG
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 1:112 MIRRAMONT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8213
Mailing Address - Country:US
Mailing Address - Phone:404-509-7986
Mailing Address - Fax:
Practice Address - Street 1:1551 PINE CREEK WAY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4355
Practice Address - Country:US
Practice Address - Phone:770-871-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist