Provider Demographics
NPI:1861601510
Name:BEATTIE, SHANNON GORMEL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GORMEL
Last Name:BEATTIE
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 1:5382 OLLIE ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:FL
Mailing Address - Zip Code:33834-8985
Mailing Address - Country:US
Mailing Address - Phone:863-767-9974
Mailing Address - Fax:
Practice Address - Street 1:1962 VANDOLAH RD
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-8726
Practice Address - Country:US
Practice Address - Phone:863-767-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist