Provider Demographics
NPI:1417441627
Name:WYNNE, SHANNON LEIGH (BCBA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LEIGH
Last Name:WYNNE
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 1:110 PINYON PINE CIR APT 1101
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5690
Mailing Address - Country:US
Mailing Address - Phone:770-827-2410
Mailing Address - Fax:
Practice Address - Street 1:110 CARLTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-5004
Practice Address - Country:US
Practice Address - Phone:770-827-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-18-30139103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst