Provider Demographics
NPI:1689722399
Name:SHAKUN, LAURA ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANNE
Last Name:SHAKUN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-1105
Mailing Address - Country:US
Mailing Address - Phone:781-438-5550
Mailing Address - Fax:781-438-5553
Practice Address - Street 1:271 MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3580
Practice Address - Country:US
Practice Address - Phone:781-438-5550
Practice Address - Fax:781-438-5553
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7113103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50623Medicare ID - Type UnspecifiedPSYCHOLOGY PROVIDER