Healthcare Provider Details

I. General information

NPI: 1194301663
Provider Name (Legal Business Name): SHANNON LEIGH LOCKHART SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6929 OUTREACH WAY
NORTH PORT FL
34287-3493
US

IV. Provider business mailing address

4944 BELLA TERRA DR
VENICE FL
34293-6074
US

V. Phone/Fax

Practice location:
  • Phone: 941-371-8820
  • Fax:
Mailing address:
  • Phone: 915-539-6127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number18230
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: