MEDICARE: SHANNON ELIZABETH DEDOMENICO MA, CCC-SLP

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	SA7695	FL

General Provider Information

NPI Number	:	1790917326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON ELIZABETH DEDOMENICO MA, CCC-SLP

Provider Business Mailing Address
First Line	:	14305 DIPLOMAT DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-3123
Country	:	US
Telephone Number	:	813-264-1420
Fax Number	:

Provider Business Practice Location Address
First Line	:	14305 DIPLOMAT DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-3123
Country	:	US
Telephone Number	:	813-264-1420
Fax Number	:

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

Provider Enumeration Date	:	08/15/2009
Last Update Date	:	08/15/2009

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