Provider Demographics
NPI:1740292465
Name:BENNETT, SHANNON STRICKLAND (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:STRICKLAND
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4493 ARCH TRL
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-4210
Mailing Address - Country:US
Mailing Address - Phone:912-807-8255
Mailing Address - Fax:912-807-8256
Practice Address - Street 1:2976 US HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-4601
Practice Address - Country:US
Practice Address - Phone:912-807-8255
Practice Address - Fax:912-807-8256
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP 003867235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000731464CMedicaid