Provider Demographics
NPI:1366774028
Name:MILLER, SHANNON MJ (SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MJ
Last Name:MILLER
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 1:7291 CONNOR AVE
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8050 CORPORATE CIR STE 4
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-1281
Practice Address - Country:US
Practice Address - Phone:440-884-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.2010076-SP235Z00000X
OHSP9750235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1366774028Medicaid