Provider Demographics
NPI:1588035125
Name:MITCHELL, STEFANIE SHANNON (MS BCBA LABA)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:SHANNON
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:MS BCBA LABA
Other - Prefix:
Other - First Name:STEFANIE
Other - Middle Name:SHANNON
Other - Last Name:FILLERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS BCBA
Mailing Address - Street 1:73 NEWBURY ST
Mailing Address - Street 2:STE 400
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-3042
Mailing Address - Country:US
Mailing Address - Phone:617-839-3707
Mailing Address - Fax:
Practice Address - Street 1:73 NEWBURY ST
Practice Address - Street 2:STE 400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3042
Practice Address - Country:US
Practice Address - Phone:617-839-3707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-09-5575103K00000X
MA816103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst