Provider Demographics
NPI:1144793183
Name:O'BRIEN, SHANNON (BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'BRIEN
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 1:190 RIVERSIDE ST UNIT 6B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2018
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:236 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6913
Practice Address - Country:US
Practice Address - Phone:207-661-6725
Practice Address - Fax:207-761-0783
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1-18-29414103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst