Provider Demographics
NPI:1912738378
Name:SHADE, RYAN JESSICA (SLP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JESSICA
Last Name:SHADE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 PENN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-2044
Mailing Address - Country:US
Mailing Address - Phone:814-205-1404
Mailing Address - Fax:814-201-2021
Practice Address - Street 1:501 VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-6410
Practice Address - Country:US
Practice Address - Phone:814-205-1404
Practice Address - Fax:814-201-2021
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSL002535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist