Provider Demographics
NPI:1598172694
Name:SMITH, SHANNON (MS, SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1559 STEVENS DRIVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-241-3486
Mailing Address - Fax:
Practice Address - Street 1:1559 N STEVENS DR
Practice Address - Street 2:UNIT D
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3897
Practice Address - Country:US
Practice Address - Phone:208-241-3486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2557235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist