Provider Demographics
NPI:1063950475
Name:RODEN, SHANNON (MED, SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RODEN
Suffix:
Gender:F
Credentials:MED, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 AIRPORT DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2640
Mailing Address - Country:US
Mailing Address - Phone:405-273-3388
Mailing Address - Fax:405-273-3389
Practice Address - Street 1:1604 S SEMINOLE AVE
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-3923
Practice Address - Country:US
Practice Address - Phone:918-413-9710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK218163235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK218163OtherCERTIFICATION FOR SPEECH LANGUAGE PATHOLOGY IN THE SCHOOL