Basic Information
| Provider Information | |||||||||
| NPI: | 1780750943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMINO | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
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| Credential: | SA5877 | ||||||||
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| OtherLastName: | DIMINO | ||||||||
| OtherFirstName: | SHANNON | ||||||||
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| OtherCredential: | M.A., CCC-SLP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1225 MARTIN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328256126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073068058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12702 SCIENCE DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328263016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072810441 | ||||||||
| FaxNumber: | 4072810422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 01/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA5877 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 886148000 | 05 | FL | MEDICAID |