1790359552 NPI number — HAYLEY CELESTE SHANNON MED, BCBA, LBA, COBA

Table of content: HAYLEY CELESTE SHANNON MED, BCBA, LBA, COBA (NPI 1790359552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790359552 NPI number — HAYLEY CELESTE SHANNON MED, BCBA, LBA, COBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
HAYLEY
Provider Middle Name:
CELESTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MED, BCBA, LBA, COBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790359552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 DEPAUW BLVD STE 3070
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46268-6135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-324-0885
Provider Business Mailing Address Fax Number:
317-520-8200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7627 EWING BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41042-1818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-706-1457
Provider Business Practice Location Address Fax Number:
317-520-8200
Provider Enumeration Date:
05/17/2021

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: 103K00000X , with the licence number:  270939 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1-21-49042 . This is a "BCBA CERTIFICATE" identifier . This identifiers is of the category "OTHER".




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