Provider Demographics
NPI:1063580884
Name:ELLIOTT, SHANNON (LICSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 DICKSON DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-6831
Mailing Address - Country:US
Mailing Address - Phone:508-863-0912
Mailing Address - Fax:
Practice Address - Street 1:310 COURT ST STE 103
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4372
Practice Address - Country:US
Practice Address - Phone:508-863-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2027086101YA0400X
MA1117081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000022201Medicare UPIN