Provider Demographics
NPI:1629123526
Name:LABRECQUE, SHIRLEY KELLY (PMHNP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:KELLY
Last Name:LABRECQUE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1794 BRIDGE ST STE 18B
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-2664
Mailing Address - Country:US
Mailing Address - Phone:978-219-6710
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2193
Practice Address - Country:US
Practice Address - Phone:978-788-7418
Practice Address - Fax:978-937-6853
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2282556363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1312294Medicaid
MAHEP10093Medicare UPIN