Provider Demographics
NPI:1396876090
Name:SOMERS, SHANNON (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:SOMERS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7724
Mailing Address - Country:US
Mailing Address - Phone:618-534-4891
Mailing Address - Fax:618-549-8137
Practice Address - Street 1:156 SERENITY LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-7724
Practice Address - Country:US
Practice Address - Phone:618-457-6445
Practice Address - Fax:618-529-4549
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.008780235Z00000X
IL146008780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12132012OtherASHA CERTIFICATION NUMBER