Provider Demographics
NPI:1528859188
Name:SHAFFER, BRIANNA
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1811 TABLEROCK CT SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-7105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 COVIL AVE STE 102
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2683
Practice Address - Country:US
Practice Address - Phone:888-392-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25-433106106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician