Healthcare Provider Details

I. General information

NPI: 1104515634
Provider Name (Legal Business Name): SHANNON HURLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 GILL ST
WOBURN MA
01801-1765
US

IV. Provider business mailing address

672 MAIN ST
WATERTOWN MA
02472-2131
US

V. Phone/Fax

Practice location:
  • Phone: 845-337-5477
  • Fax:
Mailing address:
  • Phone: 845-337-5477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW227747
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: