Provider Demographics
NPI:1568445708
Name:DAVIS, SHANNA HEADLEY (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:HEADLEY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:MISS
Other - First Name:SHANNA
Other - Middle Name:RENEE
Other - Last Name:HEADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:1700 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1230
Mailing Address - Country:US
Mailing Address - Phone:406-223-9241
Mailing Address - Fax:
Practice Address - Street 1:1700 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1230
Practice Address - Country:US
Practice Address - Phone:406-223-9241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1203235Z00000X
WI3872235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist