Provider Demographics
NPI:1508107350
Name:SHREWSBERRY, KURTIS (BCBA)
Entity Type:Individual
Prefix:MR
First Name:KURTIS
Middle Name:
Last Name:SHREWSBERRY
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-254-4260
Mailing Address - Fax:239-254-4261
Practice Address - Street 1:3361 PINE RIDGE RD STE 105
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3937
Practice Address - Country:US
Practice Address - Phone:239-254-4260
Practice Address - Fax:239-254-4261
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-16-22007103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017559000Medicaid