Provider Demographics
NPI:1215405444
Name:RICHARDT, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RICHARDT
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 1:110 CEDAR ST STE 10
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-3527
Mailing Address - Country:US
Mailing Address - Phone:617-168-9152
Mailing Address - Fax:
Practice Address - Street 1:110 CEDAR ST STE 10
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-3527
Practice Address - Country:US
Practice Address - Phone:617-168-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst