Provider Demographics
NPI:1194265017
Name:BLACKSON, SHANEL
Entity type:Individual
Prefix:
First Name:SHANEL
Middle Name:
Last Name:BLACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 CONSENSUS CT
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-6114
Mailing Address - Country:US
Mailing Address - Phone:702-285-9892
Mailing Address - Fax:
Practice Address - Street 1:4142 CONSENSUS CT
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-6114
Practice Address - Country:US
Practice Address - Phone:702-285-9892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician