Provider Demographics
NPI:1598209942
Name:HARRIS, SHAELYN (MED, BCBA)
Entity type:Individual
Prefix:MRS
First Name:SHAELYN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 254190
Mailing Address - Street 2:
Mailing Address - City:PATRICK AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32925-4190
Mailing Address - Country:US
Mailing Address - Phone:505-480-6033
Mailing Address - Fax:
Practice Address - Street 1:1657 RESCUE RD
Practice Address - Street 2:#44
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3504
Practice Address - Country:US
Practice Address - Phone:505-480-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-16-23057103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst