Provider Demographics
NPI:1518356336
Name:SHACKLETON, LYNDA (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:
Last Name:SHACKLETON
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22386 BUNCO CT
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-8422
Mailing Address - Country:US
Mailing Address - Phone:605-415-3611
Mailing Address - Fax:
Practice Address - Street 1:22386 BUNCO CT
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-8422
Practice Address - Country:US
Practice Address - Phone:605-415-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD316-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist