Provider Demographics
NPI:1467574483
Name:STACY, SHANNON M (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:STACY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 THORNBERRY DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5631
Mailing Address - Country:US
Mailing Address - Phone:719-210-9726
Mailing Address - Fax:
Practice Address - Street 1:3305 W END AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1035
Practice Address - Country:US
Practice Address - Phone:615-386-4900
Practice Address - Fax:618-386-4999
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0336441235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist