Provider Demographics
NPI:1700419025
Name:GILL, SHANNON (BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GILL
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 1:170 MEETING ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-3153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:2329 E WT HARRIS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5186
Practice Address - Country:US
Practice Address - Phone:704-529-9090
Practice Address - Fax:704-529-9009
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
BACB399814OtherBACB