Provider Demographics
NPI:1942606595
Name:STEVENS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STEVENS
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 1:817 10TH ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1619
Mailing Address - Country:US
Mailing Address - Phone:303-710-5631
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD STE 364
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1542
Practice Address - Country:US
Practice Address - Phone:303-710-5631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26569235Z00000X
2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF8089848OtherSELF