Provider Demographics
NPI:1043702905
Name:SHINN, STACEY RENEE (BCBA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:SHINN
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 1:3300 AIRPORT RD TRLR G18
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8116
Mailing Address - Country:US
Mailing Address - Phone:812-528-0975
Mailing Address - Fax:
Practice Address - Street 1:3322 NOE WAY APT 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1861
Practice Address - Country:US
Practice Address - Phone:812-528-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA60982073103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst