Provider Demographics
NPI:1588914683
Name:PRAVETZ, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PRAVETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 WHEATSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07419-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:228 WHEATSWORTH RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NJ
Practice Address - Zip Code:07419-2620
Practice Address - Country:US
Practice Address - Phone:845-325-0124
Practice Address - Fax:973-827-8421
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-16
Last Update Date:2012-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0135191235Z00000X
NJ41YS00459700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist