Provider Demographics
NPI:1396243119
Name:SHANER SPEECH PATHOLOGY
Entity type:Organization
Organization Name:SHANER SPEECH PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHANER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:714-393-0400
Mailing Address - Street 1:771 E SOUTHLAKE BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6354
Mailing Address - Country:US
Mailing Address - Phone:714-393-0400
Mailing Address - Fax:
Practice Address - Street 1:771 E SOUTHLAKE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6354
Practice Address - Country:US
Practice Address - Phone:714-393-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114170235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty