Provider Demographics
NPI:1447550298
Name:PRIDDY-MARIN, SHANNON (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PRIDDY-MARIN
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 EMMANUEL WAY LN
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:KY
Mailing Address - Zip Code:40176-5037
Mailing Address - Country:US
Mailing Address - Phone:310-560-9270
Mailing Address - Fax:
Practice Address - Street 1:228 EMMANUEL WAY LN
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:KY
Practice Address - Zip Code:40176-5037
Practice Address - Country:US
Practice Address - Phone:310-560-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0064103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst