Provider Demographics
NPI:1649384215
Name:WIEDENMAN, SHANNON KATHLEEN
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:WIEDENMAN
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 1:7 WYATT ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3917
Mailing Address - Country:US
Mailing Address - Phone:671-767-1834
Mailing Address - Fax:
Practice Address - Street 1:301 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2807
Practice Address - Country:US
Practice Address - Phone:617-912-7972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213356104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker