MEDICARE: MS. AUDREY MAE SHEN BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-11-9633	CA

General Provider Information

NPI Number	:	1821360033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUDREY MAE SHEN BCBA

Provider Business Mailing Address
First Line	:	3608 UNIVERSITY DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-6260
Country	:	US
Telephone Number	:	336-655-9307
Fax Number	:

Provider Business Practice Location Address
First Line	:	3608 UNIVERSITY DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-6260
Country	:	US
Telephone Number	:	336-655-9307
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2012
Last Update Date	:	04/28/2017

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