Provider Demographics
NPI: | 1942530845 |
---|---|
Name: | FARRELL, SHANNON PAULA (SLP) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHANNON |
Middle Name: | PAULA |
Last Name: | FARRELL |
Suffix: | |
Gender: | F |
Credentials: | SLP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 22424 S ELLSWORTH LOOP RD UNIT 464 |
Mailing Address - Street 2: | |
Mailing Address - City: | QUEEN CREEK |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85142-7070 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 480-757-2253 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 43507 N IRONWOOD DR |
Practice Address - Street 2: | |
Practice Address - City: | SAN TAN VALLEY |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85140 |
Practice Address - Country: | US |
Practice Address - Phone: | 480-757-2253 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2009-12-28 |
Last Update Date: | 2022-02-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103K00000X, 106S00000X, 224Z00000X, 225100000X, 225200000X, 225X00000X, 2355S0801X | ||
AZ | SLP 6283 | 235Z00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | |
No | 106S00000X | Behavioral Health & Social Service Providers | Behavior Technician | |
No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | |
No | 2355S0801X | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 1942530845 | Other | HOME HEALTH |