Provider Demographics
NPI:1376919290
Name:BARRY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BARRY
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 1:8 BOURNE ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01510-2204
Mailing Address - Country:US
Mailing Address - Phone:508-254-1393
Mailing Address - Fax:
Practice Address - Street 1:8 BOURNE ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MA
Practice Address - Zip Code:01510-2204
Practice Address - Country:US
Practice Address - Phone:508-254-1393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103TS0200X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid