Provider Demographics
NPI:1336266261
Name:GONZALEZ, SHANNON SUSANNE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:SUSANNE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-5466
Mailing Address - Country:US
Mailing Address - Phone:478-213-4604
Mailing Address - Fax:478-993-2035
Practice Address - Street 1:215 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-5466
Practice Address - Country:US
Practice Address - Phone:478-213-4604
Practice Address - Fax:478-993-2035
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005082235Z00000X
VA2202006366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000913844EMedicaid
GA000913844CMedicaid