Provider Demographics
NPI:1588170757
Name:SHANLEY, LAUREN (BCBA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:BERGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:91 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2529
Mailing Address - Country:US
Mailing Address - Phone:860-946-0362
Mailing Address - Fax:
Practice Address - Street 1:91 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-2529
Practice Address - Country:US
Practice Address - Phone:860-946-0362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-17-29108103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst