Provider Demographics
NPI:1932732674
Name:BURNS, SHANNON (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:MELITO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:364 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-3507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:139 LEOPARD RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-1809
Practice Address - Country:US
Practice Address - Phone:610-251-2017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-19-40320103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst