Provider Demographics
NPI:1104162122
Name:MURPHY, SHANE (LCSW)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MURPHY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ONECO ST STE 3
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-3440
Mailing Address - Country:US
Mailing Address - Phone:860-961-6252
Mailing Address - Fax:860-556-9147
Practice Address - Street 1:18 ONECO ST STE 3
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3440
Practice Address - Country:US
Practice Address - Phone:860-961-6252
Practice Address - Fax:860-556-9147
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008233104100000X
CT82331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008043829Medicaid