Provider Demographics
NPI:1194583062
Name:SHAW, BRANDON STEPHON (CCMA, RBT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:STEPHON
Last Name:SHAW
Suffix:
Gender:M
Credentials:CCMA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 WOODLAND HILLS DR APT 308
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4662
Mailing Address - Country:US
Mailing Address - Phone:719-722-7695
Mailing Address - Fax:
Practice Address - Street 1:421 WINDCHIME PL
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1984
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician