Healthcare Provider Details

I. General information

NPI: 1013727197
Provider Name (Legal Business Name): SHANNON STOCKDELL MS ED, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2025
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W TAYLOR ST
KOKOMO IN
46901-4554
US

IV. Provider business mailing address

125 W TAYLOR ST
KOKOMO IN
46901-4554
US

V. Phone/Fax

Practice location:
  • Phone: 765-419-0411
  • Fax: 800-727-9914
Mailing address:
  • Phone: 765-419-0411
  • Fax: 800-727-9914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-79975
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-96476
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: