Provider Demographics
NPI:1356087829
Name:SHIRLEY, NATHANIEL AUGUST (LICSW)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:AUGUST
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GOVE ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1920
Mailing Address - Country:US
Mailing Address - Phone:617-569-5800
Mailing Address - Fax:617-568-4756
Practice Address - Street 1:10 GOVE ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1920
Practice Address - Country:US
Practice Address - Phone:617-569-5800
Practice Address - Fax:617-568-4756
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2254781041C0700X
MA1251001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical