Provider Demographics
NPI:1578119806
Name:HARDISTY, SHELBY NICOLE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:HARDISTY
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6394 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1506
Mailing Address - Country:US
Mailing Address - Phone:800-345-0448
Mailing Address - Fax:
Practice Address - Street 1:6394 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1506
Practice Address - Country:US
Practice Address - Phone:800-345-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KS1-19-38659103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician