Provider Demographics
NPI:1821767922
Name:RANDOLPH, SHANNON ALYSE (MSW, LICSW)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:ALYSE
Last Name:RANDOLPH
Suffix:
Gender:
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BMC PLACE
Mailing Address - Street 2:MOAKLEY CONNECTOR OFFICE 1301
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:617-638-7147
Mailing Address - Fax:
Practice Address - Street 1:504 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2732
Practice Address - Country:US
Practice Address - Phone:617-445-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW11210001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical