Provider Demographics
NPI:1659014702
Name:WEEDEN, SHELBY NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:WEEDEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:EVANGELISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:4629 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-4107
Mailing Address - Country:US
Mailing Address - Phone:850-503-6366
Mailing Address - Fax:850-626-6132
Practice Address - Street 1:4629 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-4107
Practice Address - Country:US
Practice Address - Phone:850-503-6636
Practice Address - Fax:850-626-6132
Is Sole Proprietor?:No
Enumeration Date:2022-04-17
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
21-176087106S00000X
1-23-67411103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician