Provider Demographics
NPI:1477100816
Name:LEASON, SHANNON LEE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEE
Last Name:LEASON
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 1:112 LEICESTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862-1932
Mailing Address - Country:US
Mailing Address - Phone:781-600-3569
Mailing Address - Fax:
Practice Address - Street 1:315 LITTLETON RD FL 1
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3311
Practice Address - Country:US
Practice Address - Phone:978-856-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS59200202103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst