Provider Demographics
NPI:1821236647
Name:BURCH, SHANNON REBECCA (SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:REBECCA
Last Name:BURCH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 ROUTE 17C
Mailing Address - Street 2:
Mailing Address - City:TIOGA CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13845
Mailing Address - Country:US
Mailing Address - Phone:607-687-1206
Mailing Address - Fax:
Practice Address - Street 1:3015 ROUTE 17 C
Practice Address - Street 2:
Practice Address - City:TIOGA CENTER
Practice Address - State:NY
Practice Address - Zip Code:13845
Practice Address - Country:US
Practice Address - Phone:607-687-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist