Provider Demographics
NPI:1497260764
Name:SHELLY, BRIANNE
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:SHELLY
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 1:185 DEVONSHIRE ST STE 503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-1415
Mailing Address - Country:US
Mailing Address - Phone:617-581-9112
Mailing Address - Fax:
Practice Address - Street 1:185 DEVONSHIRE ST STE 503
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1415
Practice Address - Country:US
Practice Address - Phone:617-581-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9974101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health