Provider Demographics
NPI:1356792261
Name:ROTH, SHAYANNE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHAYANNE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 E 900 N
Mailing Address - Street 2:
Mailing Address - City:OSSIAN
Mailing Address - State:IN
Mailing Address - Zip Code:46777-9253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 E 900 N
Practice Address - Street 2:
Practice Address - City:OSSIAN
Practice Address - State:IN
Practice Address - Zip Code:46777-9253
Practice Address - Country:US
Practice Address - Phone:260-241-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9531235Z00000X
FLSA12974235Z00000X
MA9592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist