Healthcare Provider Details

I. General information

NPI: 1356822043
Provider Name (Legal Business Name): SHANNON ELIZABETH RADFORD LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 E MOUNTAIN ST
WORCESTER MA
01606-1400
US

IV. Provider business mailing address

PO BOX 149
NEW BRAINTREE MA
01531-0149
US

V. Phone/Fax

Practice location:
  • Phone: 857-763-0257
  • Fax:
Mailing address:
  • Phone: 774-277-7194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number125246
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: