Provider Demographics
NPI:1770711319
Name:COOPER, SHANNON M (SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:COOPER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E WASHINGTON ST
Mailing Address - Street 2:SUITE PA-2
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6450
Mailing Address - Country:US
Mailing Address - Phone:909-825-6716
Mailing Address - Fax:909-825-4339
Practice Address - Street 1:802 MAGNOLIA AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3104
Practice Address - Country:US
Practice Address - Phone:951-340-0070
Practice Address - Fax:951-340-9188
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17434235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist