Provider Demographics
NPI:1205592938
Name:THROGMORTON, SHANNON RAE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:THROGMORTON
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 1:7730 CARONDELET AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3314
Mailing Address - Country:US
Mailing Address - Phone:844-502-7996
Mailing Address - Fax:
Practice Address - Street 1:955 VILLA CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-6001
Practice Address - Country:US
Practice Address - Phone:618-351-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146014604235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist