Provider Demographics
NPI:1386611127
Name:SHAY, DONNA RUTH (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:RUTH
Last Name:SHAY
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:RUTH
Other - Last Name:SHANKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:122 12TH STREET EXTENSION
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2272
Mailing Address - Country:US
Mailing Address - Phone:304-487-7658
Mailing Address - Fax:304-487-7900
Practice Address - Street 1:122 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2352
Practice Address - Country:US
Practice Address - Phone:304-487-7658
Practice Address - Fax:304-487-7900
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP0100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSLP0100OtherWV STATE LICENSE
4265442OtherPALMETTO GBA MEDICARE PTAN NUMBER BLFD OFFICE
WV9400001000Medicaid
4265441OtherPALMETTO GBA MEDICARE PTAN NUMBER PCTN OFFICE