Provider Demographics
NPI:1457099822
Name:PETERS, SHANNON MCKENZIE (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCKENZIE
Last Name:PETERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 BAY STATE RD APT BF
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1812
Mailing Address - Country:US
Mailing Address - Phone:603-562-6735
Mailing Address - Fax:
Practice Address - Street 1:73 BAY STATE RD APT BF
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1812
Practice Address - Country:US
Practice Address - Phone:603-562-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11466103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist