Provider Demographics
NPI:1104333434
Name:KIESS, SHANNON (MED, BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KIESS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2074 SE DOVERBROOK ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4698
Mailing Address - Country:US
Mailing Address - Phone:772-530-0575
Mailing Address - Fax:
Practice Address - Street 1:2074 SE DOVERBROOK ST
Practice Address - Street 2:
Practice Address - City:ST LUCIE WEST
Practice Address - State:FL
Practice Address - Zip Code:34983-4698
Practice Address - Country:US
Practice Address - Phone:772-530-0575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-16-23919103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst