Provider Demographics
NPI:1194157644
Name:SHANNON, COLLEEN M (LICSW)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:SHANNON
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 1:1 ARNOLD CIR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-2250
Mailing Address - Country:US
Mailing Address - Phone:508-414-6037
Mailing Address - Fax:
Practice Address - Street 1:1 ARNOLD CIR
Practice Address - Street 2:SUITE 5
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-2250
Practice Address - Country:US
Practice Address - Phone:508-414-6037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2167651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical