Provider Demographics
NPI:1366931776
Name:COCKRAM, SHANNON SMITH (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:SMITH
Last Name:COCKRAM
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 WIDGEON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WOOLWINE
Mailing Address - State:VA
Mailing Address - Zip Code:24185-3602
Mailing Address - Country:US
Mailing Address - Phone:276-692-6054
Mailing Address - Fax:
Practice Address - Street 1:104 RUCKER ST.
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171
Practice Address - Country:US
Practice Address - Phone:276-694-3163
Practice Address - Fax:276-694-3170
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist