Healthcare Provider Details

I. General information

NPI: 1992377634
Provider Name (Legal Business Name): BENNETT SHIPLEY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

773 BANDIT TRL
KELLER TX
76248-0111
US

IV. Provider business mailing address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax:
Mailing address:
  • Phone: 817-442-9022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number5123
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-117363
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-59870
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: