Provider Demographics
NPI:1699314989
Name:BRANTLEY, SHANON Y (MCD, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANON
Middle Name:Y
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 KELSEY DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8561
Mailing Address - Country:US
Mailing Address - Phone:870-926-0152
Mailing Address - Fax:
Practice Address - Street 1:505 KELSEY DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-8561
Practice Address - Country:US
Practice Address - Phone:870-926-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1703235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist