Provider Demographics
NPI:1316585698
Name:JOHNSON, SHELBY DALE (BCBA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:DALE
Last Name:JOHNSON
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 1:807 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-6325
Mailing Address - Country:US
Mailing Address - Phone:409-877-1091
Mailing Address - Fax:409-877-1092
Practice Address - Street 1:807 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-6325
Practice Address - Country:US
Practice Address - Phone:409-877-1091
Practice Address - Fax:409-877-1092
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-19-38040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst