Provider Demographics
NPI:1184131005
Name:PAULL, SHANNON ROSE (RBT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:PAULL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MARTINGALE LN
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-3270
Mailing Address - Country:US
Mailing Address - Phone:508-241-1100
Mailing Address - Fax:
Practice Address - Street 1:80 WASHINGTON ST STE P55
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1742
Practice Address - Country:US
Practice Address - Phone:781-290-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-30
Last Update Date:2017-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-17-28654106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty