Provider Demographics
NPI:1144375098
Name:STUCKEY, SHANNON (MA-CCC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:MA-CCC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:SEALS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 SUMMER LAKES DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5126
Mailing Address - Country:US
Mailing Address - Phone:407-808-9726
Mailing Address - Fax:
Practice Address - Street 1:2400 S HWY 27
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6816
Practice Address - Country:US
Practice Address - Phone:352-394-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891506700Medicaid