Provider Demographics
NPI:1922451434
Name:SHANNON, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:SHANNON
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 1:10 MECHANIC ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2420
Mailing Address - Country:US
Mailing Address - Phone:508-792-5400
Mailing Address - Fax:508-831-0074
Practice Address - Street 1:210 BEAR HILL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1025
Practice Address - Country:US
Practice Address - Phone:781-290-4970
Practice Address - Fax:781-890-2624
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor