Healthcare Provider Details

I. General information

NPI: 1366929747
Provider Name (Legal Business Name): SHANNON KELLY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON OCONNOR

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE SOCIAL WORK SERVICES (122)
BOSTON MA
02130
US

IV. Provider business mailing address

150 S HUNTINGTON AVE SOCIAL WORK SERVICES (122)
BOSTON MA
02130
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-3570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number125829
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number225686
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125829
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: