Provider Demographics
NPI:1184089211
Name:PLANCK, SHANNON
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:PLANCK
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 1:118 DELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-3215
Mailing Address - Country:US
Mailing Address - Phone:802-734-0805
Mailing Address - Fax:
Practice Address - Street 1:378 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-5421
Practice Address - Country:US
Practice Address - Phone:802-476-4166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT144.0115343235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist