Provider Demographics
NPI:1285791053
Name:SHANNON, EVA MARIA
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:MARIA
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HESPERUS CIR
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-5205
Mailing Address - Country:US
Mailing Address - Phone:508-269-5100
Mailing Address - Fax:978-686-1281
Practice Address - Street 1:599 CANAL ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1244
Practice Address - Country:US
Practice Address - Phone:508-269-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6410103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist