Provider Demographics
NPI:1790917326
Name:DEDOMENICO, SHANNON ELIZABETH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:DEDOMENICO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14305 DIPLOMAT DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3123
Mailing Address - Country:US
Mailing Address - Phone:813-264-1420
Mailing Address - Fax:
Practice Address - Street 1:14305 DIPLOMAT DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3123
Practice Address - Country:US
Practice Address - Phone:813-264-1420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-15
Last Update Date:2009-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7695235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist