Provider Demographics
NPI:1962842161
Name:YORK, SHAVAUGHN R (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHAVAUGHN
Middle Name:R
Last Name:YORK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 AMANDA DR APT 703
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7490
Mailing Address - Country:US
Mailing Address - Phone:251-209-5053
Mailing Address - Fax:
Practice Address - Street 1:4535 FLAT SHOALS PKWY STE 301
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5039
Practice Address - Country:US
Practice Address - Phone:251-209-5053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist