Provider Demographics
NPI:1710410493
Name:LEE, SHANEL (BCBA)
Entity type:Individual
Prefix:
First Name:SHANEL
Middle Name:
Last Name:LEE
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 1:907 GOLDEN SHINER AVE
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-3307
Mailing Address - Country:US
Mailing Address - Phone:813-420-3386
Mailing Address - Fax:
Practice Address - Street 1:902 W LUMSDEN RD STE 105
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8806
Practice Address - Country:US
Practice Address - Phone:941-725-5082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-22-60917103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst