Provider Demographics
NPI:1730328840
Name:WALLACE, SHANNON D (BCBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:F
Credentials:BCBA
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Mailing Address - Street 1:3954 MURPHY CANYON RD
Mailing Address - Street 2:SUITE D105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4418
Mailing Address - Country:US
Mailing Address - Phone:858-569-0056
Mailing Address - Fax:858-569-4233
Practice Address - Street 1:3954 MURPHY CANYON RD
Practice Address - Street 2:SUITE D105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4418
Practice Address - Country:US
Practice Address - Phone:858-569-0056
Practice Address - Fax:858-569-4233
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA1-08-4562103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003073156OtherAEFCT COMPANY NPI#
26-0717497OtherFEDERAL TAX ID NUMBER (EIN)