Provider Demographics
NPI:1518136589
Name:LIST, SHELLEY (M ED BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:
Last Name:LIST
Suffix:
Gender:F
Credentials:M ED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7741 GANNON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2822
Mailing Address - Country:US
Mailing Address - Phone:314-725-9078
Mailing Address - Fax:
Practice Address - Street 1:7741 GANNON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-2822
Practice Address - Country:US
Practice Address - Phone:314-725-9078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1-03-1348103TB0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral