Provider Demographics
NPI:1720662539
Name:SHOMO, AYESHA (RBT)
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:SHOMO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2785 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-6501
Practice Address - Country:US
Practice Address - Phone:216-278-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-21-166892106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician