Provider Demographics
NPI:1780118521
Name:WISOCKY, SHANNON COLLEEN (MA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:COLLEEN
Last Name:WISOCKY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4213 CIDER PRESS RD
Mailing Address - Street 2:
Mailing Address - City:SLATINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:18080-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4213 CIDER PRESS RD
Practice Address - Street 2:
Practice Address - City:SLATINGTON
Practice Address - State:PA
Practice Address - Zip Code:18080-3158
Practice Address - Country:US
Practice Address - Phone:610-217-7482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL006206L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist