Provider Demographics
NPI:1609512664
Name:MCCORMACK, SHAWN ABIGAIL (BCBA)
Entity Type:Individual
Prefix:
First Name:SHAWN ABIGAIL
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SHAWN ABIGAIL
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2440 E VISTA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2375 E CAMELBACK RD STE 600
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3493
Practice Address - Country:US
Practice Address - Phone:602-584-9860
Practice Address - Fax:602-715-1135
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH000865103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty