Provider Demographics
NPI:1790304939
Name:SMITH, SHELBY ANN (BCBA, LBS)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKINS TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18640-1557
Mailing Address - Country:US
Mailing Address - Phone:570-905-2803
Mailing Address - Fax:
Practice Address - Street 1:1161 MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKINS TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18640-1557
Practice Address - Country:US
Practice Address - Phone:570-905-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-19-36487103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst