Provider Demographics
NPI:1770803066
Name:SHANNON, MARY KRISTEN (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KRISTEN
Last Name:SHANNON
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 1:10269 GREENFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-3773
Mailing Address - Country:US
Mailing Address - Phone:303-229-4773
Mailing Address - Fax:
Practice Address - Street 1:10269 GREENFIELD CIR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-3773
Practice Address - Country:US
Practice Address - Phone:303-229-4773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09145091235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist