Provider Demographics
NPI:1043365141
Name:GANUS, ALLISON SHANNON (MCD CCC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:SHANNON
Last Name:GANUS
Suffix:
Gender:F
Credentials:MCD CCC
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:ANN
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD-CCC
Mailing Address - Street 1:2424 DOUBLE CHURCHES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2741
Mailing Address - Country:US
Mailing Address - Phone:706-324-6112
Mailing Address - Fax:706-596-8259
Practice Address - Street 1:2424 DOUBLE CHURCHES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2741
Practice Address - Country:US
Practice Address - Phone:706-324-6112
Practice Address - Fax:706-596-8259
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006645235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52205907OtherBLUE CROSS BLUE SHIELD
GA235553474AMedicaid
GA52205907OtherBLUE CROSS BLUE SHIELD