Provider Demographics
NPI:1487392080
Name:PERREAULT, SHANNON MARIE (BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:PERREAULT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6129 SOUTHERN COMFORT DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:VA
Mailing Address - Zip Code:22728-1757
Mailing Address - Country:US
Mailing Address - Phone:540-212-8106
Mailing Address - Fax:
Practice Address - Street 1:5306 LEE HWY
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20187-9377
Practice Address - Country:US
Practice Address - Phone:540-212-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002528103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty