Provider Demographics
NPI:1154408102
Name:SMITH, SHANNON LEIGH (AUD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 E BROOMFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-4449
Mailing Address - Country:US
Mailing Address - Phone:989-773-1209
Mailing Address - Fax:989-773-4267
Practice Address - Street 1:1290 E BROOMFIELD ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4449
Practice Address - Country:US
Practice Address - Phone:989-773-1209
Practice Address - Fax:989-773-4267
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000386231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
114370OtherUCARE
MN75D75SMOtherBCBS OF MN
1011302OtherPREFERRED ONE
MN5G979EAOtherBCBS OF MN
640003663OtherRAILROAD MEDICARE
4500055OtherMEDICA
MN194317100Medicaid
41394OtherHEALTH PARTNERS
640000089Medicare ID - Type Unspecified