Provider Demographics
NPI:1609366152
Name:RUSSELL, SHAWNNA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHAWNNA
Middle Name:
Last Name:RUSSELL
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 1:6820 31ST TER N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3012
Mailing Address - Country:US
Mailing Address - Phone:860-558-7917
Mailing Address - Fax:
Practice Address - Street 1:8254 118TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5027
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13315235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist