Healthcare Provider Details

I. General information

NPI: 1245530757
Provider Name (Legal Business Name): REX CHARLES SHANGRAW BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2010
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 W INTERNATIONAL AIRPORT RD
ANCHORAGE AK
99518-1105
US

IV. Provider business mailing address

8130 PECK AVE
ANCHORAGE AK
99504-1422
US

V. Phone/Fax

Practice location:
  • Phone: 907-433-4789
  • Fax:
Mailing address:
  • Phone: 907-444-5931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: