1104913060 NPI number — SHANNON VOGT M.A., CCC-SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104913060 NPI number — SHANNON VOGT M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VOGT
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104913060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4885 WATERWITCH POINT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32806-7824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-738-3660
Provider Business Mailing Address Fax Number:
407-738-3660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4885 WATERWITCH POINT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-7824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-738-3660
Provider Business Practice Location Address Fax Number:
407-914-2186
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SA5932 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 889251200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 887873100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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