Provider Demographics
NPI:1366929747
Name:KELLY, SHANNON (LICSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:OCONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 S HUNTINGTON AVE
Mailing Address - Street 2:SOCIAL WORK SERVICES (122)
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:SOCIAL WORK SERVICES (122)
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:774-826-3570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1258291041C0700X, 104100000X
MA225686104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical