MEDICARE: SHANNON BRAGG

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	SLP007063	GA

General Provider Information

NPI Number	:	1417349267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON BRAGG

Provider Business Mailing Address
First Line	:	112 MIRRAMONT LAKE DR
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-8213
Country	:	US
Telephone Number	:	404-509-7986
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 PINE CREEK WAY
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-4355
Country	:	US
Telephone Number	:	770-871-6338
Fax Number	:

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

Provider Enumeration Date	:	03/02/2015
Last Update Date	:	09/23/2022

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Directions to “ SHANNON BRAGG ” Practice Location

Language	Start Address	Practice Location

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