Provider Demographics
NPI:1710979281
Name:TYLER, SHANNON MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:TYLER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:KIRKPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:960 DURHAM WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7950
Mailing Address - Country:US
Mailing Address - Phone:404-395-4578
Mailing Address - Fax:404-920-3396
Practice Address - Street 1:960 DURHAM WAY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7950
Practice Address - Country:US
Practice Address - Phone:404-395-4578
Practice Address - Fax:404-920-3396
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004924235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000891943GMedicaid
GA000891943HMedicaid
GA000891943EMedicaid