Provider Demographics
NPI:1730333782
Name:WORTH, SHANNON (MS CCC S/LP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:WORTH
Suffix:
Gender:F
Credentials:MS CCC S/LP
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HULICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC S/LP
Mailing Address - Street 1:PO BOX 1681
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-1681
Mailing Address - Country:US
Mailing Address - Phone:845-283-0905
Mailing Address - Fax:
Practice Address - Street 1:21 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566
Practice Address - Country:US
Practice Address - Phone:845-283-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist