Provider Demographics
NPI:1811136708
Name:WHITACRE, SHANNON L
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:WHITACRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LAMSON RD
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14223-2537
Mailing Address - Country:US
Mailing Address - Phone:716-316-8392
Mailing Address - Fax:
Practice Address - Street 1:2545 SHERIDAN DRIVE
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150
Practice Address - Country:US
Practice Address - Phone:716-833-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012425-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist