Provider Demographics
NPI:1831592971
Name:O'DONNELL, SHANNAN MARIE (MS, CFY-SLP)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:MARIE
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:MS, CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E BURNSIDE
Mailing Address - Street 2:319
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:574-274-8455
Mailing Address - Fax:
Practice Address - Street 1:1250 E BURNSIDE ST
Practice Address - Street 2:319
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2267
Practice Address - Country:US
Practice Address - Phone:574-274-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist