Healthcare Provider Details

I. General information

NPI: 1811201106
Provider Name (Legal Business Name): SHANNON ELLIS HANES M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 PACES COMMONS DR
DULUTH GA
30096-1727
US

IV. Provider business mailing address

1626 PACES COMMONS DR
DULUTH GA
30096-1727
US

V. Phone/Fax

Practice location:
  • Phone: 43-371-4064
  • Fax: 855-232-8604
Mailing address:
  • Phone: 43-371-4064
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number105149
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP006477
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: