Provider Demographics
NPI:1619446770
Name:BENSON, SHANIA LYNNE
Entity Type:Individual
Prefix:
First Name:SHANIA
Middle Name:LYNNE
Last Name:BENSON
Suffix:
Gender:F
Credentials:
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 1324
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:WA
Mailing Address - Zip Code:98591-1324
Mailing Address - Country:US
Mailing Address - Phone:360-827-4045
Mailing Address - Fax:
Practice Address - Street 1:1414 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-2019
Practice Address - Country:US
Practice Address - Phone:360-827-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANONE106E00000X
WA106E00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1234OtherNONO