Provider Demographics
NPI:1457687071
Name:SHANNON, RYAN PATRICK (LMSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:SHANNON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 ABBOTT ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON UPPER FALLS
Mailing Address - State:MA
Mailing Address - Zip Code:02464-1304
Mailing Address - Country:US
Mailing Address - Phone:862-755-3665
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:862-755-3665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA1171491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health