Provider Demographics
NPI:1700153327
Name:KELLEY, SHANNON MARIE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10530 WARWICK AVE
Mailing Address - Street 2:SUITE C5
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3132
Mailing Address - Country:US
Mailing Address - Phone:703-216-9230
Mailing Address - Fax:571-384-5815
Practice Address - Street 1:10530 WARWICK AVE
Practice Address - Street 2:SUITE C5
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3132
Practice Address - Country:US
Practice Address - Phone:703-216-9230
Practice Address - Fax:571-384-5815
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-11-9387103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst