Provider Demographics
NPI:1811201106
Name:HANES, SHANNON ELLIS (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELLIS
Last Name:HANES
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 1:1626 PACES COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1727
Mailing Address - Country:US
Mailing Address - Phone:043-371-4064
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:1626 PACES COMMONS DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1727
Practice Address - Country:US
Practice Address - Phone:043-371-4064
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105149235Z00000X
GASLP006477235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0944746-02Medicaid
0031DGOtherBLUE CROSS BLUE SHIELD
74-2745294OtherTAX ID
0031DGOtherBLUE CROSS BLUE SHIELD