Basic Information
| Provider Information | |||||||||
| NPI: | 1386611127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAY | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHANKLIN | ||||||||
| OtherFirstName: | DONNA | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS CCC SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 122 12TH STREET EXTENSION | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877658 | ||||||||
| FaxNumber: | 3044877900 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 12TH STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877658 | ||||||||
| FaxNumber: | 3044877900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP0100 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | SLP0100 | 01 | WV | WV STATE LICENSE | OTHER |