Provider Demographics
NPI:1891022927
Name:WATTS, SHANNON (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WATTS
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 1:169 TEQUESTA DR
Mailing Address - Street 2:SUITE 24E
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-2768
Mailing Address - Country:US
Mailing Address - Phone:772-215-3335
Mailing Address - Fax:772-287-0723
Practice Address - Street 1:169 TEQUESTA DR
Practice Address - Street 2:SUITE 24E
Practice Address - City:TEQUESTA
Practice Address - State:FL
Practice Address - Zip Code:33469-2768
Practice Address - Country:US
Practice Address - Phone:772-215-3335
Practice Address - Fax:772-287-0723
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist