Provider Demographics
NPI:1508109083
Name:KELLY, SHANNON (LICSW, CPCC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LICSW, CPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CENTRE ST
Mailing Address - Street 2:#6
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-2113
Mailing Address - Country:US
Mailing Address - Phone:617-642-2371
Mailing Address - Fax:
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:#61
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:617-642-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1114931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical