1508046822 NPI number — MRS. SHANNON RACHELLE FREEMAN WEISS BCBA

Table of content: MRS. SHANNON RACHELLE FREEMAN WEISS BCBA (NPI 1508046822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508046822 NPI number — MRS. SHANNON RACHELLE FREEMAN WEISS BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN WEISS
Provider First Name:
SHANNON
Provider Middle Name:
RACHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREEMAN
Provider Other First Name:
SHANNON
Provider Other Middle Name:
RACHELLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508046822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1433 N CYPRESS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62901-0785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1433 N CYPRESS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-0785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-967-9326
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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