Provider Demographics
NPI:1356572812
Name:SELF, SHEA ELIZABETH (BCBA)
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:ELIZABETH
Last Name:SELF
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SHEA
Other - Middle Name:ELIZABETH
Other - Last Name:DAHLBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2624 HOUGH RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1747
Mailing Address - Country:US
Mailing Address - Phone:256-275-7089
Mailing Address - Fax:
Practice Address - Street 1:2624 HOUGH RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1747
Practice Address - Country:US
Practice Address - Phone:256-275-7089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-08-4512103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst