Provider Demographics
NPI:1396180501
Name:CICCONE, SHANNON LYNN (MED BCBA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LYNN
Last Name:CICCONE
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 1:21 NEW RD
Mailing Address - Street 2:
Mailing Address - City:CHEPACHET
Mailing Address - State:RI
Mailing Address - Zip Code:02814-2001
Mailing Address - Country:US
Mailing Address - Phone:401-710-7195
Mailing Address - Fax:
Practice Address - Street 1:21 NEW RD
Practice Address - Street 2:
Practice Address - City:CHEPACHET
Practice Address - State:RI
Practice Address - Zip Code:02814-2001
Practice Address - Country:US
Practice Address - Phone:401-710-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1-13-12761103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst