Provider Demographics
NPI:1356440648
Name:SHATTUCK, WESLEY (MED, LCMHC)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:SHATTUCK
Suffix:
Gender:M
Credentials:MED, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 ROCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-2107
Mailing Address - Country:US
Mailing Address - Phone:603-425-2989
Mailing Address - Fax:603-425-2978
Practice Address - Street 1:226 ROCKINGHAM RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-2107
Practice Address - Country:US
Practice Address - Phone:603-425-2989
Practice Address - Fax:603-425-2978
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1409478Y0NH01OtherBLUE CROSS BLUE SHIELD NH
NH30423041Medicaid