Healthcare Provider Details

I. General information

NPI: 1124781158
Provider Name (Legal Business Name): SHANNON ELIZABETH LEWIS M.S., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2021
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12530 FAIRWOOD PKWY STE 102
BOWIE MD
20720-6357
US

IV. Provider business mailing address

12530 FAIRWOOD PKWY STE 102
BOWIE MD
20720-6357
US

V. Phone/Fax

Practice location:
  • Phone: 410-995-8388
  • Fax:
Mailing address:
  • Phone: 410-995-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-52193
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: