Provider Demographics
NPI:1952532418
Name:SALLEY, SHANNON WADE (MS, CCC-SLPD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:WADE
Last Name:SALLEY
Suffix:
Gender:F
Credentials:MS, CCC-SLPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ROSEHILL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-4843
Mailing Address - Country:US
Mailing Address - Phone:434-572-4906
Mailing Address - Fax:
Practice Address - Street 1:103 ROSEHILL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4843
Practice Address - Country:US
Practice Address - Phone:434-572-4906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-01
Last Update Date:2009-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist