Provider Demographics
NPI:1831462258
Name:SHEA, PETER M (EDD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:SHEA
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CAPTAIN BLOUNT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-2810
Mailing Address - Country:US
Mailing Address - Phone:413-244-6219
Mailing Address - Fax:
Practice Address - Street 1:19 CAPTAIN BLOUNT RD
Practice Address - Street 2:
Practice Address - City:SOUTH YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02664-2810
Practice Address - Country:US
Practice Address - Phone:413-244-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA990103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool