Provider Demographics
NPI:1992377634
Name:SHIPLEY, BENNETT (BCBA)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:SHIPLEY
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 1:2104 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-8355
Mailing Address - Country:US
Mailing Address - Phone:817-442-9022
Mailing Address - Fax:
Practice Address - Street 1:773 BANDIT TRL
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-0111
Practice Address - Country:US
Practice Address - Phone:817-442-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5123103K00000X
TXRBT-20-117363106S00000X
TX1-22-59870103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20-117363OtherBACB