Provider Demographics
NPI:1891871117
Name:MARSH, SHAVON L
Entity Type:Individual
Prefix:MS
First Name:SHAVON
Middle Name:L
Last Name:MARSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 43RD ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2306
Mailing Address - Country:US
Mailing Address - Phone:631-225-7038
Mailing Address - Fax:
Practice Address - Street 1:471 43RD ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2306
Practice Address - Country:US
Practice Address - Phone:631-225-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY57 002119231H00000X
NY58 016133235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist