Provider Demographics
NPI:1821360033
Name:SHEN, AUDREY MAE (BCBA)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:MAE
Last Name:SHEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:MAE
Other - Last Name:NIBLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:3608 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6260
Mailing Address - Country:US
Mailing Address - Phone:336-655-9307
Mailing Address - Fax:
Practice Address - Street 1:3608 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6260
Practice Address - Country:US
Practice Address - Phone:336-655-9307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-11-9633103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst