Provider Demographics
NPI:1386701431
Name:MCSHEA, COLLEEN LYNN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:LYNN
Last Name:MCSHEA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:LYNN
Other - Last Name:WEDEKIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:5601 HIGHWAY 95 N STE 308C
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404-8546
Mailing Address - Country:US
Mailing Address - Phone:928-854-5439
Mailing Address - Fax:928-854-5440
Practice Address - Street 1:5601 HIGHWAY 95 N STE 308C
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404-8546
Practice Address - Country:US
Practice Address - Phone:928-854-5439
Practice Address - Fax:928-854-5440
Is Sole Proprietor?:No
Enumeration Date:2007-01-01
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4317235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ046139Medicaid