Healthcare Provider Details

I. General information

NPI: 1013451616
Provider Name (Legal Business Name): SHANNON MARIE BURRESS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2016
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 E PARK BLVD STE 11
BOISE ID
83712-7722
US

IV. Provider business mailing address

5295 S MESA TRAIL WAY
MERIDIAN ID
83642-8442
US

V. Phone/Fax

Practice location:
  • Phone: 208-584-6130
  • Fax:
Mailing address:
  • Phone: 208-340-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-24312
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: