Provider Demographics
NPI:1689373797
Name:HANZALIK, SHANNON TEAH
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:TEAH
Last Name:HANZALIK
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 1:21 REVERE BEACH BLVD APT 518R
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-6135
Mailing Address - Country:US
Mailing Address - Phone:617-480-1042
Mailing Address - Fax:
Practice Address - Street 1:76 SUMMER ST STE 145A
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-0200
Practice Address - Country:US
Practice Address - Phone:978-309-1902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health