Provider Demographics
NPI:1932298353
Name:SHANNON, DAVID MICHAEL (LICSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NEWBURY ST STE 42
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-2833
Mailing Address - Country:US
Mailing Address - Phone:617-388-3256
Mailing Address - Fax:
Practice Address - Street 1:305 NEWBURY ST STE 42
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-2833
Practice Address - Country:US
Practice Address - Phone:617-388-3256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1102341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical