Provider Demographics
NPI:1457625048
Name:MICHALAK, SHELLY ELIZABETH (BCBA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ELIZABETH
Last Name:MICHALAK
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 1:3044 NW MOUNTAIN VW RD
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7712
Mailing Address - Country:US
Mailing Address - Phone:360-434-0399
Mailing Address - Fax:360-930-5326
Practice Address - Street 1:3044 NW MOUNTAIN VW RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7712
Practice Address - Country:US
Practice Address - Phone:360-434-0399
Practice Address - Fax:360-930-5326
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-1005103K00000X
WA1-12-1005103K00000X
1-12-10145103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA12524589OtherCAQH PROVIDER NUMBER