Provider Demographics
NPI:1629591037
Name:PATRICK, SHANNON L (MSCCCSLP)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:L
Last Name:PATRICK
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1618
Mailing Address - Country:US
Mailing Address - Phone:940-536-5539
Mailing Address - Fax:
Practice Address - Street 1:1907 REFINERY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2111
Practice Address - Country:US
Practice Address - Phone:940-665-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist