Provider Demographics
NPI:1730859026
Name:JOHNSON, SHANNON GRIFFIN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GRIFFIN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 SCHOOL AVENUE
Mailing Address - Street 2:
Mailing Address - City:WASKOM
Mailing Address - State:TX
Mailing Address - Zip Code:75692
Mailing Address - Country:US
Mailing Address - Phone:036-873-3619
Mailing Address - Fax:
Practice Address - Street 1:255 SCHOOL AVENUE
Practice Address - Street 2:
Practice Address - City:WASKOM
Practice Address - State:TX
Practice Address - Zip Code:75692
Practice Address - Country:US
Practice Address - Phone:903-687-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100750235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty