Provider Demographics
NPI:1790141620
Name:WISOR, SHELBY PAIGE (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:PAIGE
Last Name:WISOR
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:MISS
Other - First Name:SHELBY
Other - Middle Name:PAIGE
Other - Last Name:RUNGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M ED, BCBA
Mailing Address - Street 1:4007 MARATHON BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3717
Mailing Address - Country:US
Mailing Address - Phone:512-524-1374
Mailing Address - Fax:512-524-1355
Practice Address - Street 1:4007 MARATHON BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3717
Practice Address - Country:US
Practice Address - Phone:512-524-1374
Practice Address - Fax:512-524-1355
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB276915103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBACB276915OtherBCBA