Provider Demographics
NPI:1508046822
Name:FREEMAN WEISS, SHANNON RACHELLE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RACHELLE
Last Name:FREEMAN WEISS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:RACHELLE
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1433 N CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-0785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1433 N CYPRESS DR
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-0785
Practice Address - Country:US
Practice Address - Phone:618-967-9326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral