Provider Demographics
NPI:1043702905
Name:SHINN, STACEY RENEE (BCBA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:SHINN
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:STENGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3300 AIRPORT RD TRLR G18
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8116
Mailing Address - Country:US
Mailing Address - Phone:812-528-0975
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BLVD STE 7400
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4902
Practice Address - Country:US
Practice Address - Phone:808-501-1300
Practice Address - Fax:855-892-0299
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-05
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA60982073103K00000X
HIBA-937103K00000X
WA1-16-21977103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst