Provider Demographics
NPI:1487041208
Name:BURNS, SHELLEY ANN (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANN
Last Name:BURNS
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:ANN
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:765-454-9759
Practice Address - Street 1:21 S PARK BLVD STE 21
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8838
Practice Address - Country:US
Practice Address - Phone:317-449-2104
Practice Address - Fax:765-454-9759
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IN1-15-18242103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
11518242OtherBCBA CERTIFICATE
1-15-18242OtherBCBA CERTIFICATE