Provider Demographics
NPI:1376086793
Name:BATES, SHANNON (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6660 E 950 S
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84317-9726
Mailing Address - Country:US
Mailing Address - Phone:801-391-8970
Mailing Address - Fax:
Practice Address - Street 1:120 BYRON AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4106
Practice Address - Country:US
Practice Address - Phone:814-201-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-15-06331106S00000X
1-18-33764103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician