Healthcare Provider Details

I. General information

NPI: 1710779723
Provider Name (Legal Business Name): SHAWN THIEN-PHU NGUYEN VO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 UTICA DR
WORCESTER MA
01603-1622
US

IV. Provider business mailing address

483 WILLIAMS ST
LONGMEADOW MA
01106-2059
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-1954
  • Fax:
Mailing address:
  • Phone: 413-306-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

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: