Provider Demographics
NPI:1720657422
Name:SIVERLS, SHAWNETTE NICOLE
Entity Type:Individual
Prefix:
First Name:SHAWNETTE
Middle Name:NICOLE
Last Name:SIVERLS
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 1:8 FANEUIL HALL MARKETPLACE FL 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-6114
Mailing Address - Country:US
Mailing Address - Phone:646-334-3258
Mailing Address - Fax:
Practice Address - Street 1:223 COMMON ST APT 2
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4752
Practice Address - Country:US
Practice Address - Phone:646-334-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA106S00000XMedicaid
NJ106S00000XMedicaid