Provider Demographics
NPI:1023573938
Name:STANFORD, SHANNON NICOLE (BCBA)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NICOLE
Last Name:STANFORD
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 1:6601 LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5435
Mailing Address - Country:US
Mailing Address - Phone:818-795-5206
Mailing Address - Fax:
Practice Address - Street 1:5435 BALBOA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1570
Practice Address - Country:US
Practice Address - Phone:818-987-8104
Practice Address - Fax:310-933-4134
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-34024103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-18-34024OtherBCBA