Provider Demographics
NPI:1699979195
Name:DURICK, SHANNON (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DURICK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:427 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-2823
Mailing Address - Country:US
Mailing Address - Phone:763-390-0369
Mailing Address - Fax:
Practice Address - Street 1:1661 PARK RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2841
Practice Address - Country:US
Practice Address - Phone:952-403-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist