Provider Demographics
NPI:1962541102
Name:SHANLEY, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SHANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:CULLINANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:85 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3224
Mailing Address - Country:US
Mailing Address - Phone:774-247-4868
Mailing Address - Fax:
Practice Address - Street 1:85 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-3224
Practice Address - Country:US
Practice Address - Phone:774-247-4868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPENDING225XH1200X
MA1879225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHPENDINGMedicaid
NHPENDINGMedicaid