Provider Demographics
NPI:1013181171
Name:KOLDE, SHANNON M (SLP)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:M
Last Name:KOLDE
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 1:6802 PALM DR
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5358
Mailing Address - Country:US
Mailing Address - Phone:909-373-1641
Mailing Address - Fax:909-481-7765
Practice Address - Street 1:8265 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-373-1641
Practice Address - Fax:909-481-7765
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 15745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist