Provider Demographics
NPI:1235481441
Name:BALLINGER, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BALLINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108 SE COCONUT ST
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-4008
Mailing Address - Country:US
Mailing Address - Phone:772-349-6317
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:8108 SE COCONUT ST
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-4008
Practice Address - Country:US
Practice Address - Phone:772-349-6317
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-12-5021103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst