MEDICARE: MICHAEL R SHANAHAN M.DIV/LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	1279	MN
2	106H00000X	Marriage & Family Therapist	1379	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	601120738	OTHER	MA	MAGELLAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	820S5SH	OTHER	MN	BCBS
4	70010000LF0190	OTHER	MA	BCBS
5	171987	OTHER	MN	UCARE

General Provider Information

NPI Number	:	1962483313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL R SHANAHAN M.DIV/LMFT

Provider Business Mailing Address
First Line	:	1354 HANCOCK ST STE 209
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02169-5109
Country	:	US
Telephone Number	:	617-471-5686
Fax Number	:	617-471-5686

Provider Business Practice Location Address
First Line	:	1354 HANCOCK ST STE 209
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02169-5109
Country	:	US
Telephone Number	:	617-471-5686
Fax Number	:	617-471-5686

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	03/27/2024

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