Provider Demographics
NPI:1639538341
Name:KLASKA, SHANNON DAWN (BCABA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DAWN
Last Name:KLASKA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FOREST KNOLLS EST
Mailing Address - Street 2:24 SYCAMORE DRIVE
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4422
Mailing Address - Country:US
Mailing Address - Phone:217-422-6361
Mailing Address - Fax:
Practice Address - Street 1:5310 E WILLIAM STREET RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-1874
Practice Address - Country:US
Practice Address - Phone:217-422-6361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-16-22439103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst