Provider Demographics
NPI:1962483313
Name:SHANAHAN, MICHAEL R (MDIV/LMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:SHANAHAN
Suffix:
Gender:M
Credentials:MDIV/LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 HANCOCK ST STE 209
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5109
Mailing Address - Country:US
Mailing Address - Phone:617-471-5686
Mailing Address - Fax:617-471-5686
Practice Address - Street 1:1354 HANCOCK ST STE 209
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5109
Practice Address - Country:US
Practice Address - Phone:617-471-5686
Practice Address - Fax:617-471-5686
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1279106H00000X
MA1379106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA601120738OtherMAGELLAN
MN407950700Medicaid
MN820S5SHOtherBCBS
MA70010000LF0190OtherBCBS
MN171987OtherUCARE