Healthcare Provider Details

I. General information

NPI: 1962365940
Provider Name (Legal Business Name): SHANNON LEE DERBY LMHC, CAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 LORD RD STE 215
MARLBOROUGH MA
01752-4549
US

IV. Provider business mailing address

28 LORD RD STE 215
MARLBOROUGH MA
01752-4549
US

V. Phone/Fax

Practice location:
  • Phone: 781-666-2711
  • Fax:
Mailing address:
  • Phone: 781-666-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAC.100099
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17175
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: