Provider Demographics
NPI:1952894529
Name:SWAN, SHELLEY (BCBA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:SWAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E 14TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9130
Mailing Address - Country:US
Mailing Address - Phone:181-591-2255
Mailing Address - Fax:
Practice Address - Street 1:4959 UTICA RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3063
Practice Address - Country:US
Practice Address - Phone:888-228-8476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-17-27368103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst