Provider Demographics
NPI:1619623709
Name:CERVONE, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:CERVONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ALMON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-2908
Mailing Address - Country:US
Mailing Address - Phone:413-328-5137
Mailing Address - Fax:
Practice Address - Street 1:102 ALMON AVE
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-2908
Practice Address - Country:US
Practice Address - Phone:413-328-5137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-27
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer