Provider Demographics
NPI:1538575220
Name:MATTHEWS, SHANNON (BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MATTHEWS
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 1:44 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-4561
Mailing Address - Country:US
Mailing Address - Phone:858-926-9275
Mailing Address - Fax:
Practice Address - Street 1:44 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4561
Practice Address - Country:US
Practice Address - Phone:858-926-9275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-13-12876103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst