Provider Demographics
NPI:1578087763
Name:WORTHINGTON, SHANE (SLPA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 ELDON CV
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2385
Mailing Address - Country:US
Mailing Address - Phone:870-897-8892
Mailing Address - Fax:870-292-3422
Practice Address - Street 1:712 CALVIN AVERY DR STE C
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-6515
Practice Address - Country:US
Practice Address - Phone:870-394-9550
Practice Address - Fax:870-292-3422
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant