Provider Demographics
NPI:1295384311
Name:LEVESQUE, SHANNON MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:LEVESQUE
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 1:4600 28TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-2047
Mailing Address - Country:US
Mailing Address - Phone:813-482-7087
Mailing Address - Fax:
Practice Address - Street 1:5216 4TH AVENUE CIR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-5621
Practice Address - Country:US
Practice Address - Phone:941-744-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-94859106S00000X
FL1-23-64870103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician