Provider Demographics
NPI:1750699153
Name:VAN BUREN, SHANNA (MA, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:
Last Name:VAN BUREN
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 1:4847 SERENE SHORES DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-5213
Mailing Address - Country:US
Mailing Address - Phone:614-446-1632
Mailing Address - Fax:706-864-8442
Practice Address - Street 1:4847 SERENE SHORES DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-5213
Practice Address - Country:US
Practice Address - Phone:614-446-1632
Practice Address - Fax:706-864-8442
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131753CMedicaid