Provider Demographics
NPI:1720194202
Name:GRIFFIN, SHANNON (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:GRIFFIN
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 1:6122 T BIRD RD
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88242-9104
Mailing Address - Country:US
Mailing Address - Phone:505-393-0755
Mailing Address - Fax:505-393-0249
Practice Address - Street 1:6122 T BIRD RD
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88242-9104
Practice Address - Country:US
Practice Address - Phone:505-393-0755
Practice Address - Fax:505-393-0249
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2891235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64838315Medicaid