Provider Demographics
NPI:1417615907
Name:WISENBURG, SHANE (RBT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WISENBURG
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 CLEVELAND PL # B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 CLEVELAND PL # B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6529
Practice Address - Country:US
Practice Address - Phone:757-416-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB734630106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician