MEDICARE: SHANNON ELYSE BOTHWELL M.S. SLP-CFY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	46002739A	IN

General Provider Information

NPI Number	:	1205215407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON ELYSE BOTHWELL M.S. SLP-CFY

Provider Business Mailing Address
First Line	:	11236 N US HIGHWAY 231
Second Line	:
City	:	ODON
State	:	IN
Zip	:	47562-5602
Country	:	US
Telephone Number	:	812-486-8596
Fax Number	:

Provider Business Practice Location Address
First Line	:	6239 S EAST ST STE A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-2088
Country	:	US
Telephone Number	:	317-442-4734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2015
Last Update Date	:	05/21/2015

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Directions to “ SHANNON ELYSE BOTHWELL M.S. SLP-CFY” Practice Location

Language	Start Address	Practice Location

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