Provider Demographics
NPI:1275631723
Name:SECRIST, SHANNON CHRISTINE (LICSW)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:CHRISTINE
Last Name:SECRIST
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 1:406 TECHNOLOGY CENTER DR UNIT 4409
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-4738
Mailing Address - Country:US
Mailing Address - Phone:530-520-9319
Mailing Address - Fax:
Practice Address - Street 1:529 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-1119
Practice Address - Country:US
Practice Address - Phone:617-756-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1263861041C0700X
CALCS235621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical