Provider Demographics
NPI:1699106369
Name:SHAYEGANI
Entity type:Organization
Organization Name:SHAYEGANI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAYEGANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-203-0409
Mailing Address - Street 1:41 LILA RD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3411
Mailing Address - Country:US
Mailing Address - Phone:617-820-8785
Mailing Address - Fax:
Practice Address - Street 1:41 LILA RD
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3411
Practice Address - Country:US
Practice Address - Phone:617-820-8785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1177161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty