Provider Demographics
NPI:1912543885
Name:BAZAN, SHANNON (BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BAZAN
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 1:9 HORSESHOE CT
Mailing Address - Street 2:
Mailing Address - City:WRIGHT CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63390-3725
Mailing Address - Country:US
Mailing Address - Phone:314-650-0206
Mailing Address - Fax:
Practice Address - Street 1:650 OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7103
Practice Address - Country:US
Practice Address - Phone:314-650-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019044273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst