Provider Demographics
NPI:1477250025
Name:PIERCE, SHANELLE
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:PIERCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 GAFFNEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4914
Mailing Address - Country:US
Mailing Address - Phone:907-687-5332
Mailing Address - Fax:
Practice Address - Street 1:526 GAFFNEY RD STE 100
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4914
Practice Address - Country:US
Practice Address - Phone:907-687-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-257906106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician