Provider Demographics
NPI:1679023295
Name:MATTISON, SHANNON MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MATTISON
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 1:18310 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99016-9514
Mailing Address - Country:US
Mailing Address - Phone:509-385-9091
Mailing Address - Fax:
Practice Address - Street 1:18310 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-9514
Practice Address - Country:US
Practice Address - Phone:509-385-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WALL61262401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician