Provider Demographics
NPI:1720647837
Name:BELLANCA, SHANNON (BCABA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BELLANCA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 BOWSPRIT RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4529
Mailing Address - Country:US
Mailing Address - Phone:213-915-8277
Mailing Address - Fax:
Practice Address - Street 1:2701 MIDWAY DR UNIT 371141
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92137-6110
Practice Address - Country:US
Practice Address - Phone:724-974-9932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician