Provider Demographics
NPI:1891131256
Name:FLETCHER, SHANE (SPEECH PATHOLOGIST)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 E BARRINGER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-3302
Mailing Address - Country:US
Mailing Address - Phone:215-329-8800
Mailing Address - Fax:215-329-8808
Practice Address - Street 1:1310 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2033
Practice Address - Country:US
Practice Address - Phone:215-329-8800
Practice Address - Fax:215-329-8808
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010819252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency