Basic Information
Provider Information | |||||||||
NPI: | 1053704536 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIRLEY | ||||||||
FirstName: | BRIGITTE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCMILLAN | ||||||||
OtherFirstName: | BRIGITTE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BCBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 430853192 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372472400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | OH | ||||||||
PostalCode: | 430853192 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372472400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2015 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-16848 | OH | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.