Provider Demographics
NPI:1477149995
Name:SAMPLE, SHEA (BCBA)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:
Last Name:SAMPLE
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 1:209 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1749
Mailing Address - Country:US
Mailing Address - Phone:484-965-9966
Mailing Address - Fax:
Practice Address - Street 1:209 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1749
Practice Address - Country:US
Practice Address - Phone:484-965-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst