Provider Demographics
NPI:1902006448
Name:GREGORY, SHANNON PAULINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:PAULINE
Last Name:GREGORY
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 1:124 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3021
Mailing Address - Country:US
Mailing Address - Phone:315-777-2659
Mailing Address - Fax:
Practice Address - Street 1:124 MONROE AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3021
Practice Address - Country:US
Practice Address - Phone:315-777-2659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6090235Z00000X
NY013829-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412311Medicaid