Basic Information
| Provider Information | |||||||||
| NPI: | 1053647651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | SHANNEN | ||||||||
| MiddleName: | MARCIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 S HENDERSON ST | ||||||||
| Address2: | |||||||||
| City: | FT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761041017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173352583 | ||||||||
| FaxNumber: | 8173352597 | ||||||||
| Practice Location | |||||||||
| Address1: | 3937 BOAT CLUB RD | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761353202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172389737 | ||||||||
| FaxNumber: | 8172389963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2009 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 80378 | TX | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.