Provider Demographics
NPI:1699358689
Name:MCTAGUE, SHANA ANN (CAGS)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:ANN
Last Name:MCTAGUE
Suffix:
Gender:F
Credentials:CAGS
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:ANN
Other - Last Name:HEALEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:NH
Mailing Address - Zip Code:03819-5138
Mailing Address - Country:US
Mailing Address - Phone:603-382-5554
Mailing Address - Fax:
Practice Address - Street 1:23 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:NH
Practice Address - Zip Code:03819-5138
Practice Address - Country:US
Practice Address - Phone:603-382-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH67047103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH67047Medicaid