Healthcare Provider Details

I. General information

NPI: 1902358708
Provider Name (Legal Business Name): SHANA FENTRESS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

2992 RODINA DR APT 572E
MELBOURNE FL
32940-6530
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone: 717-385-4162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-30488
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-33526
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: