Basic Information
| Provider Information | |||||||||
| NPI: | 1922376565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MA, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BOULEVARD | ||||||||
| Address2: | SUITE 3070 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Practice Location | |||||||||
| Address1: | 2513 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656620490 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2011 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1-11-9351 | IN | N | Other Service Providers | Specialist | 103K00000X | 1-11-9351 | IN | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-11-9351 | 01 | BCBA CERTIFICATE | OTHER | 1-11-9351 | 01 | IN | BCBA | OTHER |