Provider Demographics
NPI:1780750943
Name:DIMINO, SHANNON (SA5877)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DIMINO
Suffix:
Gender:F
Credentials:SA5877
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:DIMINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1225 MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6126
Mailing Address - Country:US
Mailing Address - Phone:407-306-8058
Mailing Address - Fax:
Practice Address - Street 1:12702 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-3016
Practice Address - Country:US
Practice Address - Phone:407-281-0441
Practice Address - Fax:407-281-0422
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5877235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886148000Medicaid