Provider Demographics
NPI:1912725805
Name:WALSH, SHANNON KAYLA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KAYLA
Last Name:WALSH
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 1:2855 BLACKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1807
Mailing Address - Country:US
Mailing Address - Phone:651-955-7933
Mailing Address - Fax:
Practice Address - Street 1:2855 BLACKSTONE AVE
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1807
Practice Address - Country:US
Practice Address - Phone:651-955-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist