Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | 1-21-50676 | |
N | 106E00000X | Assistant Behavior Analyst | 01910399 |
NPI | 1003304171 |
---|---|
Provider Name | Shannon Wilson |
First Address | Tampa, FL 33624-2073 |
Second Address | Tampa, FL 33613-1718 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2018 |
Last Update Date | 04/08/2021 |