Provider Demographics
NPI:1790359552
Name:SHANNON, HAYLEY CELESTE (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:HAYLEY
Middle Name:CELESTE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2904 FOLTZ DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2525
Practice Address - Country:US
Practice Address - Phone:859-795-3000
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY270939103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-49042OtherBCBA CERTIFICATE