Provider Demographics
NPI:1215378062
Name:SHEA, AMANDA JOAN (LICSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOAN
Last Name:SHEA
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 1:940 BELMONT ST
Mailing Address - Street 2:BUILDING 5, ROOM B108
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5596
Mailing Address - Country:US
Mailing Address - Phone:774-826-1303
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:BUILDING 5, ROOM B113
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:774-826-1303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA119334104100000X, 1041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker