Healthcare Provider Details

I. General information

NPI: 1982527743
Provider Name (Legal Business Name): SHANAN FARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1242 FOURIER DR
MADISON WI
53717-1968
US

IV. Provider business mailing address

1600 W 41ST ST STE 500
BALTIMORE MD
21211-1504
US

V. Phone/Fax

Practice location:
  • Phone: 608-662-9327
  • Fax: 608-662-9041
Mailing address:
  • Phone: 410-369-0000
  • Fax: 410-484-3129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1572
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: