Healthcare Provider Details

I. General information

NPI: 1326645425
Provider Name (Legal Business Name): SHELBY HOLTSON MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 11/04/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W TAPP RD
BLOOMINGTON IN
47403-3459
US

IV. Provider business mailing address

1923 S LIBERTY DR
BLOOMINGTON IN
47403-5146
US

V. Phone/Fax

Practice location:
  • Phone: 812-330-4460
  • Fax:
Mailing address:
  • Phone: 812-330-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-58191
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: