Provider Demographics
NPI:1235258112
Name:SHELLEY, STEPHANIE (LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SHELLEY
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 1:4 TANNERY BROOK ROW APT 16
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2758
Mailing Address - Country:US
Mailing Address - Phone:617-669-7113
Mailing Address - Fax:
Practice Address - Street 1:269 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3301
Practice Address - Country:US
Practice Address - Phone:617-669-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10226611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical