Provider Demographics
NPI:1881944015
Name:RADLO, SHANNON L (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:RADLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MCNAMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-0252
Mailing Address - Country:US
Mailing Address - Phone:860-712-8165
Mailing Address - Fax:
Practice Address - Street 1:44 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-3517
Practice Address - Country:US
Practice Address - Phone:413-739-5626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT0097821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor