Provider Demographics
NPI:1316477987
Name:THOMAS, SHANNON MARIE (SLP, MSP-CCC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:SLP, MSP-CCC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:KENNEALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSP, CCC-SLP
Mailing Address - Street 1:9921 HOLLY CENTER DR APT 314
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5154
Mailing Address - Country:US
Mailing Address - Phone:704-728-9991
Mailing Address - Fax:
Practice Address - Street 1:8919 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-9600
Practice Address - Country:US
Practice Address - Phone:704-551-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4399235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist