Provider Demographics
NPI:1215344452
Name:NICKERSON, SHAYNA (BCBA)
Entity type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SHAYNA
Other - Middle Name:
Other - Last Name:GRINDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:40 PINE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:ME
Mailing Address - Zip Code:04605-6546
Mailing Address - Country:US
Mailing Address - Phone:207-317-6546
Mailing Address - Fax:
Practice Address - Street 1:40 PINE RIDGE LN
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:ME
Practice Address - Zip Code:04605-6546
Practice Address - Country:US
Practice Address - Phone:207-317-6546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-08-4870103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst