Provider Demographics
NPI:1295361350
Name:BARAJAS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BARAJAS
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 1:7011 CAMPUS DR STE 205
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3104
Mailing Address - Country:US
Mailing Address - Phone:719-466-4809
Mailing Address - Fax:719-368-8399
Practice Address - Street 1:7011 CAMPUS DR STE 205
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3104
Practice Address - Country:US
Practice Address - Phone:719-466-4809
Practice Address - Fax:719-368-8399
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-20-113256106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician