Provider Demographics
NPI:1538657101
Name:BROUSSALIAN, SHANNON (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BROUSSALIAN
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 1:11150 BERTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11150 BERTRAND AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4005
Practice Address - Country:US
Practice Address - Phone:818-915-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-28
Last Update Date:2018-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP17445235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist