Healthcare Provider Details

I. General information

NPI: 1205956679
Provider Name (Legal Business Name): SHANA C PEREZ M. S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22808 E HIGHWAY 86
GRANBY MO
64844-7416
US

IV. Provider business mailing address

1012 HICKORY ST
CASSVILLE MO
65625-2000
US

V. Phone/Fax

Practice location:
  • Phone: 417-628-3227
  • Fax:
Mailing address:
  • Phone: 417-847-6406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number117276
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: