Provider Demographics
NPI:1548386964
Name:TAYLOR, SHANNON LEIGH (MACCCSLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SUTPHIN DR
Practice Address - Street 2:
Practice Address - City:MARMET
Practice Address - State:WV
Practice Address - Zip Code:25315-1977
Practice Address - Country:US
Practice Address - Phone:304-949-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist