Basic Information
| Provider Information | |||||||||
| NPI: | 1811201106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANES | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | ELLIS | ||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1626 PACES COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300961727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0433714064 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 PACES COMMONS DR | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300961727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0433714064 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 105149 | TX | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP006477 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0944746-02 | 05 | TX | MEDICAID | 0031DG | 01 | BLUE CROSS BLUE SHIELD | OTHER | 74-2745294 | 01 | TAX ID | OTHER |