Provider Demographics
NPI:1477208098
Name:CHAMBERLIN, SHANE (BSL)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:CHAMBERLIN
Suffix:
Gender:M
Credentials:BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-1408
Mailing Address - Country:US
Mailing Address - Phone:570-768-0184
Mailing Address - Fax:
Practice Address - Street 1:60 N 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-1446
Practice Address - Country:US
Practice Address - Phone:570-523-1297
Practice Address - Fax:570-524-4752
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005766101Y00000X, 101YP1600X, 103K00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst