Provider Demographics
NPI:1265980536
Name:ROBERTSON, SHAUNA L (BCBA)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:L
Last Name:ROBERTSON
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 1:1886 E DON CARLOS AVE UNIT 127
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-5076
Mailing Address - Country:US
Mailing Address - Phone:602-758-2155
Mailing Address - Fax:
Practice Address - Street 1:82 W RAY RD
Practice Address - Street 2:# 104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-8537
Practice Address - Country:US
Practice Address - Phone:602-758-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-16-22904103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst