Provider Demographics
NPI:1558704916
Name:MCNEILLY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCNEILLY
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 1:176 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-2561
Mailing Address - Country:US
Mailing Address - Phone:508-765-5940
Mailing Address - Fax:508-753-5051
Practice Address - Street 1:176 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-2561
Practice Address - Country:US
Practice Address - Phone:508-765-5940
Practice Address - Fax:508-753-5051
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1308785Medicaid
MAM18684OtherBLUE CROSS BLUE SHEILD
MA1306421Medicaid
MA22220002001OtherBLUE CROSS BLUE SHEILD
MA1306421Medicaid