Provider Demographics
NPI:1700419025
Name:GILL, SHANNON (BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-4653
Mailing Address - Country:US
Mailing Address - Phone:843-934-1968
Mailing Address - Fax:
Practice Address - Street 1:328 GLEN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-4653
Practice Address - Country:US
Practice Address - Phone:843-934-1968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
BACB399814OtherBACB