Provider Demographics
NPI:1689157760
Name:STEPHENS, SHANNON (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STEPHENS
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 1:1403 HONAKER AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-3065
Mailing Address - Country:US
Mailing Address - Phone:304-487-1551
Mailing Address - Fax:
Practice Address - Street 1:2503 GOODWINS CHAPEL RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24739-4484
Practice Address - Country:US
Practice Address - Phone:304-898-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1917235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist