Healthcare Provider Details

I. General information

NPI: 1720739824
Provider Name (Legal Business Name): EHSAN ADIB SHABAHANG PHD, LMHC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LANDSDOWNE ST APT 1810
CAMBRIDGE MA
02139-4247
US

IV. Provider business mailing address

68 HARRISON AVE STE 605 PMB 866561
BOSTON MA
02111-1929
US

V. Phone/Fax

Practice location:
  • Phone: 617-906-6767
  • Fax: 617-693-6040
Mailing address:
  • Phone: 617-906-6767
  • Fax: 617-693-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number88146
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401224763
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberTPMC3794
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10003605
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10501
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number20487
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: