Provider Demographics
NPI:1790847556
Name:HEPBURN, SHANNON M III (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:HEPBURN
Suffix:III
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 CEDARHURST DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-6445
Mailing Address - Country:US
Mailing Address - Phone:404-918-5392
Mailing Address - Fax:678-493-4710
Practice Address - Street 1:257 CEDARHURST DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-6445
Practice Address - Country:US
Practice Address - Phone:404-918-5392
Practice Address - Fax:678-493-4710
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist