Provider Demographics
NPI:1588816938
Name:O'BRIEN, SHANNON (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 DIMOCK ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1029
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:617-442-1702
Practice Address - Street 1:55 DIMOCK ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1029
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-442-1702
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1163881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical