Provider Demographics
NPI:1114371309
Name:BROOKS, SHELBY (BCBA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BROOKS
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 1:2013 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5307
Mailing Address - Country:US
Mailing Address - Phone:850-391-6060
Mailing Address - Fax:
Practice Address - Street 1:515 PALM COAST PKWY SW
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4739
Practice Address - Country:US
Practice Address - Phone:386-951-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-21590103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst