Provider Demographics
NPI:1508996026
Name:WEATHERBY, SHANNON M (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:WEATHERBY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-2655
Mailing Address - Country:US
Mailing Address - Phone:636-343-5466
Mailing Address - Fax:
Practice Address - Street 1:2101 VALLEY DR
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-2655
Practice Address - Country:US
Practice Address - Phone:636-343-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017835235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist