Provider Demographics
NPI:1588311955
Name:SHEAD, COURTNEY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SHEAD
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 1:1301 E YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75602-2251
Mailing Address - Country:US
Mailing Address - Phone:903-343-1650
Mailing Address - Fax:
Practice Address - Street 1:1301 E YOUNG ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-2251
Practice Address - Country:US
Practice Address - Phone:903-343-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065702501Medicaid