Provider Demographics
NPI:1336596626
Name:ZIMMERMAN, SHANNON (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:RUDESILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 WOODDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2933
Mailing Address - Country:US
Mailing Address - Phone:651-738-9888
Mailing Address - Fax:651-738-9889
Practice Address - Street 1:2101 WOODDALE DR STE A
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2933
Practice Address - Country:US
Practice Address - Phone:651-738-9888
Practice Address - Fax:651-738-9889
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9483235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist