Provider Demographics
NPI:1952634578
Name:NICHOLS, SHANNON LISA (MA, BCBA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LISA
Last Name:NICHOLS
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 1:90 N HILL DR
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-5718
Mailing Address - Country:US
Mailing Address - Phone:856-359-6349
Mailing Address - Fax:
Practice Address - Street 1:90 N HILL DR
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-5718
Practice Address - Country:US
Practice Address - Phone:856-359-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-03-1101103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst