Provider Demographics
NPI:1831661701
Name:BEATTY, SHANNON NICHOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICHOLE
Last Name:BEATTY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICHOLE
Other - Last Name:SPEAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3840 HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7277
Mailing Address - Country:US
Mailing Address - Phone:817-569-4300
Mailing Address - Fax:
Practice Address - Street 1:3934 KENSINGTON DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-3616
Practice Address - Country:US
Practice Address - Phone:817-504-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114158235Z00000X
TN7423235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist