Provider Demographics
NPI:1497242333
Name:THOMPSON, SHANNON (CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:4560 SOUTH BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1160
Mailing Address - Country:US
Mailing Address - Phone:757-490-3223
Mailing Address - Fax:757-490-2936
Practice Address - Street 1:4560 SOUTH BLVD STE 310
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1160
Practice Address - Country:US
Practice Address - Phone:757-490-3223
Practice Address - Fax:757-490-2936
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008214235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist