Provider Demographics
NPI:1306462585
Name:WELLER, SHANNON (MS, LBA, BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:MS, LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 N 27TH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5742
Mailing Address - Country:US
Mailing Address - Phone:847-508-4347
Mailing Address - Fax:
Practice Address - Street 1:5025 E WASHINGTON ST STE 212
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-7439
Practice Address - Country:US
Practice Address - Phone:602-773-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst