Provider Demographics
NPI:1922376565
Name:WHITE, SHANNON LYNN (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BOULEVARD
Mailing Address - Street 2:SUITE 3070
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:765-454-9759
Practice Address - Street 1:2513 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3241
Practice Address - Country:US
Practice Address - Phone:765-662-0490
Practice Address - Fax:765-454-9759
Is Sole Proprietor?:No
Enumeration Date:2011-12-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1300103K00000X
IN1-11-9351103K00000X, 174400000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1-11-9351OtherBCBA
1-11-9351OtherBCBA CERTIFICATE
TNQ090505Medicaid